THE 



DISEASES OF CHILDREN 



BY HENRY ASHBY, M.D., F.R.C.P. 

Sixth Edition. With /.// Illustrations. Fcp. 8vo. price $1.50. 

NOTES ON PHYSIOLOGY FOR THE USE 
OF STUDENTS. 

Second Edition. With 25 Illustrations. Crow?/ 8vo. $r.2j. 

HEALTH IN THE NURSERY. 



BY G. A. WRIGHT, F.R.C.S. 

With 48 Original Woodcuts, Etc. 

HIP DISEASE IN CHILDHOOD. 



[Out 0/ print. 



LONGMANS, GREEN, & CO. 

J ondon, New York, and Bombay. 



THE 



DISEASES OF CHILDREN 



MEDICAL AND SURGICAL 



/ BY 

HENRY ASHBY, M.D.Lond., F.R.C.P. 

PHYSICIAN TO THE GENERAL HOSPIlg^ FOR SICK CHILDREN, MANCHESTER" 

LECTURER AND EXAMINER IN DISEASES OF CHILDREN IN THE VICTORIA UNIVERSITY 

FORMERLY LECTURER ON PHYSIOLOGY IN THE OWENS COLLEGE 

AND IN THE LIVERPOOL SCHOOL OF MEDICINE 

AND 

G. A. WRIGHT, B.A., M.B.Oxon., F.R.C.S.Eng. 

ASSISTANT SURGEON TO THE MANCHESTER ROYAL INFIRMARY 

AND SURGEON TO THE CHILDREN'S HOSPITAL 

LECTURER ON PRACTICAL SURGERY IN THE OWENS COLLEpE 

FORMERLY EXAMINER IN SURGERY IN THE UNIVERSITY OF OXFORD 

CORRESPONDING MEMBER OF THE AMERICAN ORTHOPAEDIC ASSOCIATION 



FOURTH EDITION 

EDITED FOR AMERICAN STUDENTS 

BY 

WILLIAM PERRY NORTHRUP, A.M., M.D. 

PROFESSOR OF PEDMTPICS, THE UNIVERSITY A.ND BEL I EVI'E HOSPITAL MEDICAL COLLEGE 

ATTENDING PHYSICIAN NEW "ORK FOUNDLING. WIILVRT PARIXEK, AND PRESBYTERIAN HOSPITALS 

CONSULTING PHYSICIAN NEW YORK INFANT ASYLUM 

MEMBER OF THE ASSOCIATION OF AMERICAN PHYSICIANS 



LONGMANS, GREEN, AND CO. 

91 AND 93 FIFTH AVENUE, NEW YORK 

LONDON AND BOMBAY 

1900 

L." 



THE U8»a*v OF 

CONGRESS. 
G*t Co^v Rcctivto 

JUL, 11 1901 

Co»»"IGHT W«T*v 

Class &mu n, . 
COPY B. 






Copyright, 1893, BV 
LONGMANS, GREEN, AND CO. 

Copyright, 1895, Bv 
LONGMANS, GREEN, AND CO. 

Copyright, 1899, ^ v 
LONGMANS, GREEN, AND CO. 

AH rights reserved 



Press of J. J. Little & Co. 
Astor Place, New York 



THE SURGICAL PART OF THIS BOOK I DEDICATE 
TO MY FATHER 



G. A. WRIGHT 



7T. 



NOTE TO THE 

AMERICAN EDITION 



In preparing this edition for the American Reader it has been 
thought best to leave the body of the book intact. The same disease 
differs but little in its course in America and in England ; it is neces- 
sary, therefore, to note only such differences in theory and in treat- 
meut as shall seem to bring the book into accord with present 
> merican practice. This has been done by means of the Appendix, 
cai t being taken to refer supplementary matter to its proper connec- 
1 in the main work by page references, and by additions to the 

The Formulae (page 865) have been entirely rewritten to conform 
to the United States Pharmacopoeia. 

The supplementary additions to the Surgical portion of the book 
have been made by Dr. T. Halsted Myers, Attending Orthopaedic 
Surgeon to St. Luke's Hospital, and Foundling Hospital, New 
York, whose contributions are also embodied in the Appendix. 

The Editor trusts that these additions may still further increase 
the usefulness among American readers of this complete and con- 
densed treatise, which has so quickly passed to its fourth edition. 

W. P. N. 



PREFACE 



TO 

THE FOURTH EDITION 



1\ preparing the Fourth Edition the whole of the work has been 
thoroughly revised, and many of the chapters have been entirely re- 
written. Considerable additions have been made in the text, some 
sixty pages, twenty-five new photographs, and fourteen plates having 
been added. 

We must express our best thanks to Mr. A. Wilson, F.R.C.S., for 
rewriting the chapter on Anaesthetics, to our colleague Dr. H. R. Hum >\, 
for the use of some of his clinical cases, and to Dr. E. M. Brockbank 
for much kindly help and for the care and trouble he has taken in 
reading through the proof-sheets. 

HENRY ASHBY, 
G. A. WRIGHT. 
Manchester: September, 1899. 



PREFACE 



TO 



THE FIRST EDITION 



The present work is intended to give to senior students and junior 
medical practitioners a fairly complete, though necessarily condensed, 
account of the various morbid conditions peculiar to, or chiefly found 
during, infancy and childhood. Those diseases which are neither special 
to children nor modified by their occurrence in early life are either 
omitted altogether or only briefly considered. 

The book is written from a practical point of view, and but little 
pathological detail will be found in it. 

The basis of our work is our experience at the General Hospital 
for Sick Children, Manchester, an institution at which some 1,200 
in-patients and some 10,000 out-patients are annually treated. Our 
observations have extended over nearly ten years, and during the whole 
of that time we have been collecting material both at the Children's 
Hospital and at the Royal Infirmary for this purpose. 

The original feature of this book is that it is written conjointly by a 
physician and a surgeon ; it is hoped that it presents, therefore, a fairly 
complete account of disease in children. Though we are well aware 
that the book is not an exhaustive treatise, we think it will be found 
practical, and it is at least based on experience and is not a mere 
compilation. 

The illustrations are almost entirely taken from photographs of 
cases that have been under our own care ; where this is not so, their 
source is acknowledged. 



x Diseases of Children 

We have to tinder our cordial thanks to our friends a\\(\ colleagues, 
both at the Children's Hospital and at the Royal [nfirmary, for their 
help. Our thanks are also due to successive generations of house 
surgeons who have kept the records of our cases. 

To our colleague, I )r. Hutton, for allowing us without stint the use 
of his cases, as well as for much help and advice in correcting our 
proofs, our especial thanks are due ; also to Messrs. Southam and 
Collier, our colleagues at the Royal Infirmary and the Children's 
Hospital, for their care and kindness in proof-reading. To Mr. WlLSON 
we owe our chapter on Anaesthetics, which is made especially valuable 
by his large experience in the administration of these agents both at the 
Children's Hospital and at the Royal Infirmary. To Drs. Humphrevs 
and Massiah, our former colleagues, we are also indebted for the use 
of their notes of cases. 

We must also acknowledge the help rendered to us by Messrs. Paine 
and Benger in connection with the formulae for medicines and external 
applications given in this work. 

We cannot take leave of our work without further acknowledging 
our indebtedness to the Board of Governors of the Children's Hospital 
for their generous treatment of us, and especially for enabling us to 
publish our annual abstract of cases treated at the Hospital. We also 
desire to express our appreciation of the value of the work of our sisters 
and nurses in making observations of cases, and in the preparation of 
temperature charts. 

To Messrs. Longman, our publishers, we are much indebted for 
their liberality in allowing us to borrow woodcuts from their published 
works, and for their help in many ways ; we desire also to acknowledge 
the great pains and skill shown by Mr. Pearson in engraving our 
photographs. 

HENRY ASHKV, 
G. A. WRIGHT. 
Manchester : May 1889. 



CONTENTS 



CHAPTER I 

THE PHYSIOLOGY OF INFANCY AND CHILDHOOD 

The periods of life, I ; intra-uterine life, I ; infancy, r ; childhood, 2 ; youth, 2 ; 
respiration, 3 ; changes in the circulation after birth, 4 ; amount of blood in 
body, 5 ; pulse, 5 ; alimentary canal, 6 ; urine, 7 ; temperature, 8 ; nervous 
system, 8 ; sight, 9 ; hearing, 9 ; taste, 10 ; psychical phenomena, 10 ; sleep, 10 ; 
body weight, 10; dentition, 12; mortality, 14 

CHAPTER II 

THE DISEASES INCIDENT TO BIRTH 

Asphyxia neonatorum, 17 ; apoplexia neonatorum, 19 ; cephalhematoma, 21 ; hema- 
toma of the sterno-mastoid, 24 ; occipital hematoma, 25 ; obstetrical paralysis, 
25 ; icterus neonatorum, 26 ; hemorrhagic diathesis, 28 ; acute fatty degenera- 
tion of the newly-born, 29 ; WinckeFs disease, 29 ; gastro-intestinal haemorrhage, 
30; hemorrhage from the genital organs, 30; diseases of the navel, 31 ; um- 
bilical polypus, 31; omphalitis, 32; gangrene of the navel, ^2 ; umbilical 
arteritis, 33 ; umbilical phlebitis, 34 ; umbilical hemorrhage, 34 ; tetanus 
nascentium, 35 ; sclerema neonatorum, 36 ; oedema neonatorum, 37 ; gonor- 
rhoea! ophthalmia, 37 



CHAPTER III 

THE HYGIENE AND DIET OF INFANTS AND CHILDREN 

New-born infants, 38 ; clothing, 39 ; infant feeding, 39 ; wet nurses, 41 ; weaning, 
42 ; artificial feeding, 44 ; cow's milk, 44 ; woman's milk, 46 ; modified milk, 
48 ; whey, 50 ; diluted milk, 51 ; barley water, &c, 51 ; peptonised milk, 52 ; 
sterilisation, 52 ; condensed milk, 53 ; dried milk foods, 54 ; amount of food, 
55 ; feeding bottles, 56 ; diet from 6 to 12 months, 56 ; diet from 12 months 
to 18 months of age, 57 ; after 18 months, 57 ; the care of immature and weakly 
infants, 58 ; incubators, 59 



xiv Diseases of Children 

CHAPTER XV 

THE SPECIFIC FEVERS {continued) 

Diphtheria, 278 ; pharyngeal form, 281 ; malignant, 283 ; nasal diphtheria, 283 ; 
laryngeal, 284 ; wound diphtheria, 284 ; complications, 284 ; pseudo-diphtheria, 
290 ; epidemic influenza, 290; enteric fever, 293 ; complications, 297 ; typhus, 
303; varicella, 305 ; varicella gangraenosa. 308; vaccinia, 309; complications, 
310; varioloid, 311; whooping cough, 312; complications, 315; mumps 
parotitis, 318 ; malarial fever, 319 



CHAPTER XVI 

DISEASES OF THE RESPIRATORY APPARATUS 

The thorax in infancy and childhood, 321 ; congenital laryngeal stridor, 322 ; laryn- 
gismus stridulus — child -crowing — spasm of the glottis, 323 ; spasmodic laryn- 
gitis, 327 ; compression of trachea, 328 ; catarrhal laryngitis, 329 ; membranous 
laryngitis, 332 ; tracheotomy, 336 ; intubation of the larynx, 346 ; chronic 
laryngitis, 348 ; papilloma of the larynx, 349 



CHAPTER XVII 

DISEASES OF THE RESPIRATORY APPARATUS {cOJltimied) 

Bronchitis and catarrh, 351 ; collapse of the lung, 353 ; bronchiectasis and emphy- 
sema ; 353 ; chronic bronchitis and bronchiectasis, 354 ; broncho-pneumonia, 
355 ; secondary pneumonias, 357 ; chronic broncho-pneumonia, 358 ; different 
types of pneumonias, 360 ; croupous pneumonia, 366 ; gangrene of lung, 374 ; 
abscess of the lung, 375 ; pleurisy and empyema, 375 ; asthma, 386 ; diseases 
of the bronchial glands, 387 ; mediastinal abscess, 388 ; lymphadenoma, 390 ; 
chronic tuberculosis of the lungs, 390 ; fibroid phthisis, 393 



CHAPTER XVIII 

DISEASES OF THE CIRCULATORY SYSTEM 

Diseases of the heart, 396 ; congenital heart disease, 397 ; patent foramen ovale, 
398 ; patent septum ventriculorum, 400 ; stenosis of the pulmonary and tricuspid 
orifices, 400 ; stenosis of the aorta or mitral valves, 401 ; transposition of the 
aorta and pulmonary artery, 402 ; pericarditis, 402 ; endocarditis, 407 ; chronic 
heart disease, 410 ; acute myocarditis, 415 ; mediastino-pericarditis, 417 ; Ray- 
naud's disease, 420 



Contents xv 

CHAPTER XIX 

DISEASES OF THE CIRCULATORY SYSTEM {continued) 

Naevus, 421 ; stellate naevus, 421 ; port- wine mark, 421 ; cutaneous naevus, 422 ; 
subcutaneous naevus, 422 ; mixed nsevus, 422 ; simple nsevi, 422 ; cavernous 
naevi, 422 ; lymphatic nsevi, 428 ; aneurism, 430 

CHAPTER XX 

DISEASES OF THE BLOOD AND BLOOD-MAKING ORGANS 

Anaemia, 432 ; anaemia with cedema, 433 ; simple anaemia, 433 ; idiopathic anaemia, 
434 ; scurvy, 435 ; enlarged spleen, 436 ; anaemia splenica, 437 ; Hodgkin's 
disease, 449 ; leukaemia, 439 ; haemophilia, 440 ; purpura simplex, 442 ; peliosis 
rheumatica, 444 ; diseases of the retro-peritoneal glands, 444 

CHAPTER XXI 

SYPHILIS 

Syphilis, 446 ; acquired syphilis, 446 ; hereditary syphilis, 447 

CHAPTER XXII 

RHEUMATISM— DIABETES 

Rheumatism, 458; complications, 459; chronic rheumatism, 461 ; arthritis defor- 
mans, 461 ; chronic arthritis with glandular enlargement, 462 ; diabetes mellitus, 
463 ; polyuria — diabetes insipidus, 464 

CHAPTER XXIII 

DISEASES OF THE NERVOUS SYSTEM 

Introduction, 466 ; clinical examination, 467 ; cerebral congestion, 468 ; tubercular 
meningitis, 468 ; simple meningitis, 477 ; acute form, 477 ; posterior basal 
meningitis, 479 ; cerebro-spinal meningitis, 480 ; latent form, 481 ; chronic 
meningitis, 482 ; endarteritis, softening, 484 ; acute hydrocephalus, 485 ; chronic 
hydrocephalus, 485 ; hypertrophy of the brain, 489 ; atrophy of the brain — 
sclerosis of the brain, 489 ; tumours of the brain, 491 ; tumours of the cerebellum, 
493 ; of the pons, 496 ; basal ganglia and internal capsule, 496 ; of the cortex, 
496 ; of the frontal lobe, 497 ; cerebral abscess, 498 ; cerebral haemorrhage, 501; 
post-partum haemorrhage — birth palsy, 502 ; cerebral haemorrhage occurring after 
birth — acute cerebral palsy, 504 ; medullary haemorrhage, 510 ; embolism, 511; 
thrombosis of the cerebral sinuses and veins, 514 



xvi Diseases of Children 

CHAPTER XXIV 

DISEASES OF THE NERVOUS SYSTEM {continued) 

Chorea, 515; hemichorea, 522; epilepsy, 526; hysteroid fits, 528; post-hemiplegic 
epilepsy, 529 ; infantile convulsions — eclampsia, 532 ; tetany, 537 ; nystagmus, 
539 ; head-nodding, 539 ; head-banging, 540 ; hysteria, 540 ; headaches, 543 ; 
night terrors, 545 

CHAPTER XXV 

DISEASES OF THE NERVOUS SYSTEM (continued) 

Speech anomalies, 546 ; deaf-mutism, 547 ; acquired deaf-mutism, 548 ; physical 
defects in the mouth, 549 ; mental defect, 549 ; aphasia, 550 ; stammering, 
550; mental affections in childhood, 551 ; congenital group, 552; Mongols, 
554 ; microcephalic, 554 ; hydrocephalic, 555 ; eclampsic, 555 ; epileptic, 555 ; 
developmental idiocy, 556 ; accidental or acquired, 556 ; backward children, 
557 ; idiocy due to syphilis, 557 ; cretinoid idiocy, 559 



CHAPTER XXVI 

DISEASES OF THE NERVOUS SYSTEM (continued) 

Spina bifida, 566 ; meningocele, 570 ; spinal meningitis, 572 ; paraplegia, 573 ; 
myelitis, 575 ; Landry's paralysis, 577 ; hereditary ataxic paraplegia— -Friedrich's 
disease, 577 ; anterior polio-myelitis — acute atrophic paralysis — infantile para- 
lysis, 578 ; progressive muscular atrophy, 586; peripheral neuritis, 587.; pseudo- 
hypertrophic paralysis, 588 ; juvenile form of muscle atrophy, 590 ; muscle 
atrophy of the face, 591 ; Thomsen's disease, 591 



CHAPTER XXVII 

DISEASES OF THE GENITO-URINARY SYSTEM 

Abnormal conditions of urine, 592 ; lithsemia, 592 ; hematuria, 593 ; intermittent 
hemoglobinuria, 594 ; pyuria, 594 ; cystinuria, 594 : albuminuria in apparently 
healthy children, 594 ; congenital anomalies of the kidneys, 596 ; movable 
kidney, 596 ; renal new growths, 597 ; tuberculous kidney, 600 ; hydronephrosis, 
601 ; renal calculus, 602 ; acute pyelitis, 602 ; acute nephritis, 603 ; septic 
nephritis, 604 ; acute parenchymatous nephritis, 604 ; chronic nephritis, 605 ; 
Addison's disease, 607 



Contents xvii 

CHAPTER XXVIII 

DISEASES OF THE GENITO-URINARY SYSTEM {continued) 

Stone in the bladder, 609 ; cystitis, 613 ; incontinence of urine, 614 ; retention, 616 ; 
malformations of the genito-urinary organs — extroversion of the bladder, 617 ; 
epispadias, 620 ; hypospadias, 620 ; phimosis, 622 ; balanitis, 624 ; congenital 
paraphimosis, 624 ; masturbation, 625 ; oedema of the scrotum, 625 ; diseases 
of the external genitals in females, 625 ; vulvitis, 625 ; noma pudendi, 627 ; 
irritable mamma, 627 ; abnormalities in the descent of the testicles, 627 ; super- 
numerary testicles, 631 ; congenital displacement or hernia of the ovary, 631 ; 
acute orchitis, 631 ; syphilitic testitis, 632 ; tubercular disease, 632 ; tumours of 
the testis, 633 ; hydrocele, 633 ; hydrocele in girls, 634 ; varicocele, 635 ; 
ovarian tumours, 635 

CHAPTER XXIX 

DISEASES OF THE BONES 

Diseases of the bones, 636 ; acute periostitis, 637 ; acute osteomyelitis, 645 ; acute 
epiphysitis, 646 ; chronic periostitis, 648 ; chronic circumscribed osteomyelitis, 
652 ; chronic diffuse osteomyelitis, 654 ; strumous dactylitis, 657 ; syphilitic 
dactylitis, 659 ; leontiasis ossea, 659 

CHAPTER XXX 

DISEASES OF THE JOINTS 

Tubercular disease of the shoulder, 664 ; disease of the elbow-joint, 664 ; of the 
wrist, 665 ; of the ankle, 666 ; acute synovitis, 667 ; pyaemic joint disease, 668 ; 
exanthematous synovitis, 668 ; chronic rheumatic arthritis, 669 ; syphilitic 
synovitis, 669 ; acute suppurative arthritis of infants, 670 ; acute tuberculous 
synovitis, 672 ; erasion, 676 ; excision, 677 ; sacro-iliac disease, 684 ; disease of 
the temporo-maxillary joint, 685 ; hysterical joints, 685 

CHAPTER XXXI 

HIP DISEASE 
Chronic hip disease, 687 ; acute hip disease, 690 

CHAPTER XXXII 

SPINAL DISEASE 
Caries of the spine, 713 ; costo-vertebral disease, 726 



xviii Diseases of Children 



CHAPTER XXXIII 

CLUB-FOOT, DEFORMITIES OF LIMBS, ETC. 

Talipes equino-varus, 727 ; T. valgus, 728 ; T. equinus, 729 ; paralytic or acquired 
talipes, 736; flat-foot, 738; wry-neck or torticollis, 740; deficiencies of mus- 
cles, 743 ; tenosynovitis, 743 ; various congenital malformations, 743 ; super- 
numerary digits, 746 ; club-hand, 747 ; web-fingers, 749 ; congenital rigidity of 
joints and contractions, 749 ; congenital dislocations, 750 



CHAPTER XXXIV 

DISEASES OF THE NOSE 

Acute catarrh, 754 ; chronic catarrh, 754 ; nasal polypi, 756 ; malformations, 756 ; 
epistaxis, 757 ; nasal deformity, 757 



CHAPTER XXXV 

DISEASES OF THE EAR 

Diseases of the external ear, 758 ; affections of the external meatus, 758 ; inflamma- 
tion of the middle ear, 759 ; of the labyrinth, 762 ; intracranial abscess, 762 



CHAPTER XXXVI 

TUMOUR GROWTH IN CHILDHOOD 

Sarcomata, 764 ; neuroma, 765 ; enchondroma, 766 ; exostosis, 767 ; cystic tumours, 
767 ; fatty growths, 770 ; giant foot, 771 ; compound congenital tumours, 772 ; 
congenital sacral tumour, 773 ; lymphoma, 775 ; cystic growths of the -jaws, 776 



CHAPTER XXXVII 

DISEASES OF THYROID' AND THYMUS 
Acute enlargement of the thyroid, 777 ; goitre, 777 ; thymus, 778 

CHAPTER XXXVIII 

DISEASES OF THE SKIN 

Eczema, 780 ; impetigo, 787 ; seborrhcea, 787 ; erythematous eruptions, 788 ; roseola, 

788 ; erythema scarlatiniforme, 788 ; chilblains, 789 ; erythema multiforme, 

789 ; erythema nodosum, 789 ; urticaria, 790 ; urticaria papulosa, 790 ; lichen 



Contents xix 

scrofulosus, 790 ; psoriasis, 791 ; pityriasis rubra, 791 ; miliaria — sudamina, 

791 ; miliaria rubra, 791 ; pemphigus, 791 ; dermatitis, 792 ; drug- eruptions, 

792 ; tinea tonsurans, 793 ; tinea circinata, 794 ; alopecia areata, 796 ; favus, 
796 ; scabies, 796 ; pediculosis, 796 ; flea-bites, 797 ; midge-bites, 797 ; harvest- 
bug, 797 ; simple onychia, 797 ; onychia maligna, 797 ; lupus, 798 ; papilloma, 
799 ; hairy and pigmented moles, 799 



CHAPTER XXXIX 

INJURIES, SHOCK, HEMORRHAGE, ETC. 

Injuries to the head, 800 ; traumatic cephalhydrocele, 800 ; fracture of the base of 
the skull, 801 ; injuries to the chest, 801 ; injuries to the abdomen, 801 ; injuries 
of the limb, 801 ; greenstick fractures, 802 ; ununited fractures, S02 ; separation 
of the epiphyses, 803 ; primary amputations, 812 ; primary resections, 812 ; 
dislocations, 812 ; burns and scalds, 813 ; shock, 814 ; loss of blood, 814 ; 
pain, 814; septic diseases, 815 



CHAPTER XL 

ANAESTHETICS FOR CHILDREN 

General anaesthesia, 816 ; choice of an anaesthetic, 818 ; local anaesthesia, 818 ; 
cocaine, 818 ; nitrous oxide, 818 ; chloroform, 819 ; ether, 819 ; A. C. E. 
mixture, 820 ; preparation, 820 ; vomiting, 823 ; anaesthetics in special opera- 
tions, 823 ; accidents, 824 ; Calot's operation, 825 

APPENDIX 827 

FORMULA ....!'. S65. 

INDEX '.."....-.".■'.■.'. 877 



LIST OF ILLUSTRATIONS 



PLATES 



, 



743 




747 


/'' 


75i 
752 


1/ 



PLATE 

I. Hip disease, with ' travelling acetabulum ' . . . to face p 

II. Skiagram of the arm and chest wall in a case of myositis 

ossificans, showing the bony spines and plates in the muscles , , 

III. Skiagram of a case of club-hand, with arrest of development 

of the radial (praeaxial) border of the limb . . . ,, 

IV. ' Congenital dislocation ' of the hip. The acetabulum is 

seen far below the head of the femur. . . . . ,, 

V. ' Congenital dislocation ' of the hip, the fellow to Plate IV. ,, 

VI. Beatrice D. , set. i\ years. Separation of the whole lower 
epiphysis of the humerus, with inward displacement of a 
vertical split in the shaft. The diaphysis projects out- 
wards. Loss of ' carrying angle ' . . . . . , , 806 

VII. Separation of the lower epiphysis of the humerus, with back- 
ward displacement . - . . . . . . . ,, 806 

VIII. Separation of lower epiphysis of humerus, with "T" fracture. 
Subluxation of radius forwards. Injury four years ago. 
Good mobility. Boy set. 1 1 years . . . . . , , 806 

IX. Separation of the capitellar in a girl aet. 7 years. There was 
mobility through about 70 , and good power of pronation 
and supination. A points to loose fragment . . . ,, 806 

X. Separation of the lower epiphysis of the radius in a boy 

aet. 10 years „ 807 .. 

XI. Separation of radial epiphysis, with arrest of growth two 
years later. Boy aet. 12 years. A centre of ossification 
for the styloid process of the ulna exists . . . ,, 807 ^' 

XII. Separation of the lower epiphysis of the femur, with vertical 

fracture of the shaft. From a young man aet. 1 8 years . , , 808 ^ 

XIII. Fracture above epiphysial line of lower end of humerus. 

Loss of ' carrying angle. ' Boy aet. 6 years. Injury four 

months ago ......... ,, 810V 

XIV. Fracture of neck of femur, possibly diastasis. Boy aet. 1 1 

years ,, 811 > 



XX11 



Diseases of Children 



IN TEXT 



iFIG. 

1. Stomach of a newly born infant (natural size) 

2. Weight chart, showing normal weights during first year 

3. Lower jaw of an infant at birth, showing dental sacs 

4. Lower jaw of a child about three years of age 

5. Meningeal haemorrhage in an infant 

6. Double cephalhematoma . 

7. Section of a cephalhematoma 

8. Section of an ileo- umbilical diverticulum 

9. Bottle for allowing milk to stand . 

10. Infant's feeding-bottle 

11. Fungus of thrush .... 

12. Deformity of mouth due to cancrum oris 

13. Vertical section of human tonsil 

14. Temperature chart of epidemic tonsillitis 

15. Congenital stenosis of the pylorus . 

16. Hour-glass constriction of stomach . 

17. Thread worm .... 

1 8. Eggs of thread worm 

19. Ileo-crecal intussusception 

20. Intussusception removed by operation 

21. Longitudinal section of fig. 20 

22. Scheme of lines of union of face 

23. Double incomplete hare-lip . 

24. Severe double hare-lip 

25. Diagrams of hare-lip operations 

26. Macrostoma ..... 

27. Branchial fistuke in a girl 

28. Supernumerary auricle in neck . 

29. Tracing of chest wall of a rickety boy 

30. Enlargement of epiphyses of lower end of radius and ulna 

31. Section through radius of case figured in fig. 30 

32. Longitudinal section through the junction of a rib and its carti 

rickety child .... 

33. Transverse section through the shaft of the ulna of a rickety 

34. Rickety deformity of the femora .... 

35. Shows the attitude assumed by child, fig. 34 . 

36. The same child as that figured in 34, limbs straightened 

37. A child aged 7 years, showing extreme stunting 

38. Rickety curvature of the spine 

39. A case of knock-knees . . . . ... 

40. A child sitting cross-legged ..... 

41. A case of bow-legs . . . ... 

42. X A case of severe rickets ...... 

43. Thomas's splint for genu valgum .... 

44. Lateral curvature of the spine 



lage 



child 



from 



List of Illustrations 



xxin 



45- 
46. 
46a 

47- 
48. 
49. 
50- 
5i- 
52. 
53- 
54- 
55- 
56. 

57. 
58. 

59- 
60. 
61. 
62. 

63. 
64. 
65. 
66. 
67. 
68. 
69. 
70. 

7i. 

72. 

73- 
74- 
75- 
76. 

77- 
78. 

79- 
80. 
81. 
82. 
83- 
84. 
85. 
86. 
87. 



90. 

9i. 

92. 



Reclining board for lateral curvature 

Miliary tubercles of the choroid .... 

Tubercular ulceration of skin of foot . 
Temperature chart of acute ostitis in an infant . 

,, ,, erythema nodosum 

,, ,, scarlet fever .... 

,, ,, mild scarlet fever . 

,, ,, malignant scarlet fever 

,, ,, post-scarlatinal nephritis 

,, ,, cases of measles 

,, ,, measles with broncho-pneumonia 

,, ,, mild enteric fever 

,, ,, * enteric fever 

,, ,, ,, ,, with peritonitis 

,, ,, typhus fever 

,, ,, chicken pox .... 

Varicella gangrenosa ...... 

Temperature chart of modified smallpox . 
Anatomy of child's trachea ..... 

Parker's tracheotomy tube ..... 

O'Dwyer's intubation apparatus .... 

O'Dwyer's extractor ...... 

Papilloma of the larynx ..... 

Temperature chart of broncho-pneumonia . 

,, ,, acute fatal broncho-pneumonia 

, , , , a case of acute lobar pneumonia 

,, ,, croupous Dneumonia 

,, ,, ,, ,, treated with cold bath 

,, ,, pleuro-pneumonia followed by empyema 

Deformity of chest due to empyema . 
Caseous glands in the mediastinum 
Plan of fcetal circulation . 
Stenosis of pulmonary artery . 



Temperature chart of acute endocarditis 

Acute endocarditis of mitral valves . 

Chronic mediastino-pericarditis 

Mixed nsevus of face 

Naevus of face .... 

Orbital nsevus ..... 

Arterio-venous varix 

Ncevus lipomatodes .... 

Degenerated naevus of scalp . 

Lymphatic naevus of foot . 

Gangrene of the leg following embolism 

Fissures around the mouth in congenital syphilis 

Congenital syphilis ..... 

Destruction of the nose in congenital syphilis 

Diseases of bone in congenital syphilis . 



PAGE 

226 

233 
241 

247 
248 
252 
253 
254 
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268 
269 
295 
297 
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306 

307 
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338 
342 
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356 
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369 
37i 
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385 
389 
399 
401 
402 
408 
411 
418 
422 

423 
426 

427 
428 

429 
429 
43o 
449 
45o 
451 
452 



xxiv Diseases of Children 



FIG. 



'AG1 



93. Syphilitic epiphysitis 455 

94. Chronic arthritis with glandular enlargement 462 

95. Tracing of ' Cheyne-Stokes' respiration 471 

96. Microcephalic infant 482 

97. Meningoencephalitis .......... 483 

98. Sclerosis ol brain ........... 484 

99. Chronic hydrocephalus .......... 486 

100. „ „ 487 

1 01. Atrophy of the left side of the cerebrum 490 

102. Transverse section of the cerebrum 491 

103. Spastic paralysis ........... 502 

104. Results of tenotomy in spastic paralysis . . . . . . 502 

105. Spastic paralysis, mental feebleness . . . • 504 

106. Section of brain, showing blood-cysts ....... 506 

i°7- >> >> >> >> 5°7 

108. Brain, showing effects of old meningeal haemorrhage .... 509 

109. Medulla, showing haemorrhage . . . .. . . . . 511 

no. Transverse section of medulla, showing haemorrhage . . . 511 

in. Section of brain, showing effects of embolism . . . . . . 512 

112. Cyst formed in brain as the result of embolism . . . . .513 

113. Tetany 537 

114. » ' ' . • 538 

115. Hysterical hemiplegia . . . . . . . . . 541 

116. Mongol imbecile ........... 555 

117. Cretin ... 560 

118. „ 561 

U9- » • 562 

120. ,, after treatment . . . . . . . . . . 563 

121. „ 504 

122. „ „ „ 565 

123. A case of cured spina bifida, with talipes . 568 

124. Section through a spina bifida cured by injection 569 

125. Spontaneous cure of spina bifida ........ 570 

126. Occipital meningocele 571 

127. Frontal meningocele . . . . . . . . . . 571 

128. Acute atrophic paralysis 582 

129. » >, » 5 8 3 

130. Acute muscular atrophy ......... 586 

131. Pseudo-hypertrophic paralysis . . . 589 

I3 2 - » » >> 589 

133. Growth in the kidney . . 598 

134. Congenital renal sarcoma ......... 599 

135. Result of a plastic operation for extroversion of the bladder in a boy . . 619 

1 36. Undescended testis seen as a swelling in the inguinal canal . . . 629 

137. Diagram showing the commoner fopms of hydrocele of the vaginal process 634 

1 38. Acute periostitis of the femur ......... 639 

139. Overgrowth of the bones of the right leg ...... 644 

140. Syphilitic disease of both tibiae . . . . . . . . 649 

T41. Epiphysitis of the upper end of the right humerus ..... 653 



List of Illustrations 



xxv 



Multiple tuberculous dactylitis 

Overgrowth of thumb as the result of tuberculous disease 
Results of tuberculous dactylitis .... 
Tuberculous disease of the wrist .... 
Tuberculous disease of the ankle joint 
Congenital syphilitic synovitis of both wrists . 
Showing the results of erasion of knee 

Showing the result of premature use of the limb after operation 

Splint for disease of the ankle and tarsus 

Resection of the tarsus ...... 

Showing the result of excision of the os calcis 
Diagram showing the parts most frequently affected in 
Disease of head of femur ..... 

Section of the head of femur, showing disease . 
Specimen, showing disease of the acetabulum 
Lordosis in hip disease ...... 

Position of the limb in the second stage of hip disease 
Side view of the same ...... 

Bryant's splint . . . . 

Method of applying extension in hip disease 
Thomas's hip splint applied ..... 



hip disease 



Result of excision of the hip .... 

Caries of the spine ...... 

Attitude in spinal caries .... 

Jury-mast for spinal caries . 

Patterns of Thomas's splints for spinal disease 
Caries of .the spine treated with Tnomas's splint 
Severe talipes equino-varus .... 

Very severe talipes equino-varus 
Talipes produced by ' bad packing ' 
Little's tin splint . . . . 

Artificial muscle applied 

Little's tin talipes shoe 

Acquired talipes ..... 

Acquired talipes calcaneus 

Flat-foot 

Artificial muscle for flat-foot 
Congenital wry-neck .... 
Artificial muscle for congenital wry-neck 
Double thumb ..... 
Intra-uterine amputation . ... 

Arrest of development of limb 
Club-hand ..... 

Double club-hand ..... 
Genu recurvatum and talipes calcaneus 
Abnormal position in utero, causing genu 
Congenital dislocation of both hips . 



recurvatum, &c 



PAGE 

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74i 

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749 

750 
75i 



xxv i Diseases of Children 

I'lG- PAGE 

191. Sarcoma of lower jaw and eyeball ........ 764 

192. Knchondroma of spine and fingers ........ 765 

193. Multiple enchondromata of finger . . . . . . . 766 

194. Hygroma of neck with macroglossia . ....... 767 

195. Congenital serous cyst of back ........ 767 

196. Dermoid cyst of orbit .......... 768 

197. ,, ,, forehead 769 

198. ,, ,, in lachrymal fissure . ... . . . . . 770 

199. Myxo-lipoma of breast . . . . . . . . . .771 

200. Giant foot 771 

201. Congenital cystic tumour of groin ........ 772 

202. Congenital sacral tumour .......... 773 

203. Section of congenital sacral tumour ....... 774 

204. Lymphoma of neck ........... 776 

205. Cystic bronchocele ........... 778 

206. Hairy mole of face and scalp . . . . . . . . . 798 

207. Separation of the upper epiphysis of the right humerus .... 804 

208. Plan of the development of the humerus ....... 805 

209. Separation of trochlear epiphysis of humerus ..... 806- 

210. Arrest of growth of the radius ......... 806 

211. Separation of the lower epiphysis of the radius ..... S07 

212. Separation of lower epiphysis of left femur . . . . . 808 

213. Dislocation of the patella ......... 813 

214. Freeman's Pasteurizing apparatus ........ 830 

215. Short large calibre tubes . . . . . . . . . 833 

216. Built-up head for granulations ......... 835 

217. New York Orthopaedic Hospital brace for knock-knee and bow-legs . 836 

218. Knight's bow-leg brace .......... 836 

219. Boston Children's Hospital brace for bow-legs . . . . . . 836 

220. The Davis-Taylor long traction hip-splint ...... 844 

221. Bradford-Gold thwaite brace for correcting deformity at the knee . 845 

222. Taylor's spinal brace with chin-cup 847 

223. Whitman's flat-foot support . . . 849 

224. Shaffer's flat-foot support . . S50 



DISEASES OF CHILDREN 



CHAPTER I 

THE PHYSIOLOGY OF INFANCY AND CHILDHOOD 

Tlie Periods of Early life. — The life of man is naturally divided into 
three great epochs — viz. a period of Growth and Developme?it, of Maturity, 
and of Decline. 

The first division includes the periods of early life, when those series of 
operations are in progress by which the ovum or primitive germ is trans- 
formed into the complete organism ; it may be subdivided into Intra-uterine 
Life, Infancy, Childhood, Youth, and Adolescence. 

Intra-uterine life. — During this epoch the embryo depends entirely 
upon its parent for all its wants. The maternal blood supplies it with 
material for constructive purposes, carries away its waste products, and 
renders unnecessary the maintenance of an independent temperature. It is 
clearly a time of great importance to the future being, and it is necessary 
that this development should take place under healthy conditions, inasmuch 
as it is physiologically impossible for an unhealthy or weakly mother to supply 
the wants of the embryo, and any failure in the nutritive powers of the mater- 
nal blood is certain to leave its stamp on the future development of the child. 
An infant may come into the world fairly well developed and plump, from 
the presence of more or less stored-up fat, in spite of the weakly state of the 
mother's health, but it is almost certain sooner or later to exhibit tendencies 
to disease in the direction of the stock from whence it springs. Not only 
may the embryo owe a weakly building-up of its tissues to its mother, but it 
may actually share maternal disease. The foetus may suffer from endo- 
carditis originating in a rheumatic state of its parent, and this lesion affecting", 
as it usually does, the right side of the heart, may lead to malformations, 
which are only too likely to cut short its career. From its parents also the 
foetus may receive the virus of syphilis, from which it may suffer during its 
embryonic life or after birth. It may receive an inheritance of tuberculosis 
or epilepsy, or a tendency to gout or rheumatism. During foetal life many 
anomalies may arise from arrested development or an overgrowth in certain 
directions : cleft palate and hare-lip are instances of the former, and super- 
numerary fingers and nsevoid growths of the latter. 

Infancy. — The Romans used the word infans'm its widest sense, and 
though, as its derivation implies, it was originally applied to those who could 

B 



2 The Physiology of Infancy and ( hi Id hood 

not speak, it came to be employed by them for children of much older years. 
The terms infancy, premiere enfance and Sauglingsperiode are most usually 
applied to the first seven or eight months of life, the time during which the 
infant is nursed at the breast, and before the eruption of the milk teeth. It 
is, however, used by some writers to include the whole of the first year. 
Within the first week or two of life the infant has often to contend with con- 
ditions which arc peculiar to this period, inasmuch as they depend in one 
way or another on the act of birth. It may be born asphyxiated in con- 
sequence of strangulation by the cord or pressure on the head ; various 
injuries producing hematomas may take place ; or there may be septic in- 
fection in connection with the umbilical cord. The change from placental 
alimentation to the digestion of food in the infant's stomach is a time of 
peculiar danger, especially if artificial food is given, and the mortality 
of infants is much greater during the first week of life than at any other 
period. 

During the first few months of infancy, life is not so purely vegetative as 
it is during the intra-uterine period, yet the mental faculties are in abeyance 
and the movements mostly involuntary or reflex. 

One consequence of the undeveloped condition of the higher or inhibitory 
centres is that the reflex centres are less under control than in later years, so 
that disorderly reflex movements in the form of convulsions are liable to take 
place on the slightest provocation. Growth at this period is extremely rapid, 
the weight more than doubling" itself during the first six months of life, and a 
great strain is thus thrown on the alimentary system ; the lymphatic and 
blood-forming organs are also exceedingly active. It is not surprising, there- 
fore, that the diseases which are most common and fatal at this period are 
those connected with digestion and absorption. The infant requires much 
rest, and, indeed, divides its time for the most part between feeding and 
sleeping. It is during this period that ' wasting,' ' marasmus,' or k atrophy ' is 
so common, a result of chronic catarrh of the intestinal tract and a con- 
sequent impairment of the digestive organs. 

Childhood. — The eruption of the milk teeth marks an epoch in early 
life, the term childhood being applied to the period commencing with the 
first dentition and ending with the commencement of the second, at the 
sixth or seventh year. The terms seco?ide enfance and Kinderalter are used 
in a similar sense. Growth at this period continues to be active, though not 
proceeding at the same rate as during infancy, but disturbances of the ali- 
mentary system are common, and children quickly waste if digestion and 
absorption are interfered with. 

The osseous and muscular systems are developing so that by the end of 
the first year the child can crawl or even walk with help. It is at the com- 
mencement of this period that rickets, a disease so intimately associated 
with indigestion, often makes its appearance. The mental faculties are 
opening out as the brain develops, and the infant begins to recognise its 
friends and call them by name. During the period of dentition nervous 
disturbances are common, and the lesions giving rise to infantile paralysis 
are apt to take place. 

Youths — The terms youth, jeunesse and Knabenalter are generally applied 
to the period commencing at the second dentition and ending at puberty, or 



Youth — Respiration 3 

about the fourteenth year. During this time the milk teeth are replaced by 
the permanent set, the bones become more solid and the muscles better 
developed, while the mental faculties are exceedingly acute and the mind 
readily acquires knowledge. As puberty approaches, the voice becomes 
deeper and the sexual organs undergo a marked increase of development. 
During this period, in which scholastic education is carried on, the memory 
is exceedingly retentive, perhaps more so than at any other time. Children 
at this period easily ' outgrow their strength,' the nervous system is readily 
upset, as is evidenced by the frequency of chorea, and the alimentary canal 
is apt to suffer from chronic catarrh. 

Respiration. — During intra-uterine life the respiration of the foetus is 
carried on by means of the placenta. The blood of the foetus— as far as 
oxygen is concerned — is supplied in a far more imperfect manner through 
the maternal blood, than when after birth the oxygen is taken direct from 
the air in the vesicles of the lungs. Inasmuch as the foetus has no inde- 
pendent temperature to maintain, and its life is spent in continuous sleep, 
its tissues require far less oxygen than it does after birth. This condition 
of things induces a tolerance of oxygen starvation, much greater than in 
adults, that frequently stands it in good stead during the act of birth, when 
the placental circulation is perhaps interfered with through pressure on the 
umbilical cord, and pulmonary respiration as yet is not possible. Infants 
are often born in a condition of asphyxia, especially after severe labours, and 
have been known to survive without either placental or pulmonary respira- 
tion for 10 to 15 minutes, and infants may live for many hours, or even days, 
with the greater part of their lungs in an unexpanded state. The same 
tolerance of a venous condition of blood occurs in other newly born animals ; 
thus Brown-Sequard has shown that a newly born mouse will recover after 
an immersion of 10 minutes in water, a newly born guinea-pig after 12 
minutes, while an immersion of 3 to 3^ minutes is fatal to the adult animals. 

In the newly born the respirations amount to about 44 per minute ; 
during the early months of life they vary from 35 to 40 per minute ; at the 
end of the first year and commencement of the second they have fallen to 
about 28 ; during the third and fourth years they are about 25 ; by the 
fifteenth year they have fallen to 20 ; in the adult they vary from 16 to 20. 
Infants and children, as might be expected, give off absolutely less carbonic 
acid than do adults, but relatively more. This may perhaps be accounted 
for by their greater activity (see page 4). 

The absorption of oxygen is also relatively greater in childhood than in 
adult life ; the oxygen in the exhaled carbonic acid does not represent all 
the inhaled oxygen, the proportion retained being greater in childhood than 
in adult life. 

In the infant and during the first three years of life the type of respira- 
tion is the abdominal, the diaphragm being the chief muscle used in tranquil 
respiration, the abdomen rising and falling, and the ribs moving but little. 
Later the costo-inferior type is present, respiration takes place by means of 
the intercostals, and also by the diaphragm, the chest expanding and the 
abdomen moving slightly. In girls towards puberty the costo-superior type 
is present, the upper part of the chest moves freely, the lower part and the 
abdomen hardly at all. 



4 The Physiology of Infancy and Childhood 

The vital cubic capacity of the lungs is smaller in proportion to their 
height in children than in adults. This is due in part to the relative small- 
ness of their lungs and to the greater elasticity and flexibility of their chest 
walls. 

According to Schnepf and Wintrich the vital cubic capacity at different 
ages is shown by the following table : 

3 to 4 years . . about 450 c.c. 11 to 12 years . . about 1,800 c.c. 

5 ■• 7 • • » 900 c.c. 13 „ 14 „ . . „ 2,200 c.c. 

8 „ 10 „ . . „ 1,300 c.c. In adults (average) „ 3,300 c.c. 

With regard to the amount of carbonic acid given out by children, the 
following account of an experiment made by the late Dr. Angus Smith, of 
Manchester, is of interest. We quote his own words : ' Four children, three 
boys of 6, 7, and 8 years respectively, and one girl of 7, were put into the 
lead chamber which was made for similar experiments, and in order to 
observe them more carefully Dr. Ashby sat beside them. They were 
extremely quiet, and the amount of carbonic acid given out was exactly one- 
half of that which experiment had given me in previous years for a healthy 
man of moderate strength. The amount given out by Dr. Ashby was 
estimated in a separate experiment, and subtracted from that given out by 
the children, which was equal in amount to 0*361 of a cubic foot per hour for 
each. The children were then put in by themselves and became very 
riotous and active, causing the carbonic acid to rise up for each to 0-531 of 
a cubic foot. They were then put in again and requested to be very quiet. 
They had a few cards to play with, and talked a great deal, but were bodily 
pretty still, upon which the carbonic acid fell down nearly to the first amount 
— viz. 0-4139 of a cubic foot. We find that talking raised the amount of 
carbonic acid only 0-0529 of a cubic foot, whilst jumping and laughing- 
raised it 0*1687, or about three times as much.' 

The circumference of the chest on an average measures : 

6 years 22 inches 

7 „ 22^ „ 

9 „ 24 „ 

10 „ 24^ „ 



13 inches 


17 


?) 


19 


5) 


20 


3J 


21* 


?) 



Birth . . 
6 months 
12 „ 

2 years . 
4 „ 

Changes in tne Circulation after Birth. — The cessation of the placental 
circulation, the inflation of the lungs with air, and consequently the increased 
amount of blood passing through the pulmonary artery, lead to a gradual 
shrinking and obliteration of the various fcetal passages — viz. the vessels of 
the cord, the ductus venosus, ductus arteriosus, and foramen ovale. These 
changes commence after the first few respirations have been taken, and 
within a week or ten days these passages are closed. Not infrequently, 
however, one or other of them remains open for a much longer period, this 
being especially true of the foramen ovale. In 62 cases under 2 years of 
age noted by Parrot, it was only completely obliterated in four ; and of 52 
cases between 2 and 9 years, in 26 only was it completely closed. 

With regard to the ductus arteriosus, Parrot found that of 187 cases of 
1 month to 3 years, in 46 it was open, in 18 it was partially closed, and in 1 19 



Blood — Pulse 5 

it was obliterated. The ductus venosus is mostly obliterated within three 
days ; according to Quincke its remaining partially open gives rise to 
icterus. 

Blood. — During the last few years, many observations have been made 
of the blood of the newly born and also of young infants, with the object of 
determining the differences as regards the number and character of the 
corpuscles as compared with adults. The results of various observers are 
in some cases at variance, and some care is required in drawing conclusions. 
The results given must not be taken as being universally correct. The 
nucleated red blood corpuscles found during the early months of intra-uterine 
life are only very exceptionally to be seen in the blood of the newly born 
when born at full time. The red corpuscles are more numerous in the 
newly born (5,000,000 to 6,000,000 per cub. mill.) than in the adult, and also 
vary more in size (Hayem). In a few weeks this disparity in numbers dis- 
appears, the number of corpuscles falling to 4,000,000-5,000,000. The 
quantity of Hb is also greater in the newly born, but falls rapidly during the 
first few days or weeks ; it is lower during childhood than during adult 
life (Leichenstern). The leucocytes are also both relatively and absolutely 
more numerous ; the greater number are of the small mono-nuclear 
variety (lymphocytes). The eosinophile cells are also increased (Kanthack). 
The amount of fibrin-formers appears to be less as coagulation occurs less 
completely. The amount of blood in the body is relatively less than in 
adults, being one-nineteenth of the body weight, while in the adult it is one- 
thirteenth (Welcker). In older children in health the blood does not 
appear to materially differ from the blood of adults. 

Pulse. — At the end of fcetal life the number of cardiac contractions per 
minute is about 132 in boys and 140 in girls ; in the newly born infant it has 
fallen to 130 to 133. According +0 some observations, the pulse rate falls 
notably immediately after the ligature of the cord, to regain its normal 
number an hour or two later. During the week succeeding birth it varies 
from 120 to 140, crying immediately increasing the number some 10 to 30 
beats. By the second year it has fallen to no, by the fifth to 100, by the 
eighth to 90, and by the twelfth to 80. 

During sleep the pulse rate is diminished, especially in infants, some- 
times by as much as 10 or 20 beats. The pulse is more often irregular 
in infants and children than in adults, and this apart from the influence of 
disease. 

According to Soltmann the inhibitory action of the vagus is less marked 
in newly born animals than in adults. The circulation of the blood in 
infants and children is carried on more rapidly than in adults, and conse- 
quently the tissues are supplied with a superabundance of arterial blood. 
The tension in the arteries is comparatively low, on account of the relatively 
large size of the aorta and arterial system generally. 

According to Yierordt a complete circulation takes 

In newly born infants in 12 seconds (134 pulse rate) 
At two years . .15 „ (107 „ ) 

At fourteen years . 18*6 „ (87 „ ) 

In adults . . . 22 „ (72 „ ) 



6 The Physiology of Infancy and C liildhood 

( )n account of the proneness of the pulse to be influenced by excitement 
during infancy, it is of less value in diagnosis at this period than in later years. 

Alimentary canal. — For the first six to eight weeks of life there is very 
slight secretion of saliva, only sufficient being formed to render the mouth 
moist. In the third and fourth months the secretion is much more free, so 
that infants about this period begin to dribble ; the amount of secretion be- 
comes still larger as the period of dentition approaches. By the third or 
fourth month the saliva contains ptyalin, and readily converts cooked starch 
into maltose. The stomach of the newly born infant is small, its capacity 
being one or two fluid ounces, by the end of the fourth week from three to 
four ounces, at three months about five ounces, and at the end of the first 
year ten ounces. The muscular layers of the stomach and intestines are at 
first only slightly developed, hence the feebleness of the peristaltic action 
and the tendency to the accumulation of gases in both the stomach and 
bowels. The gastric juice has at first but imperfect digestive powers, and 
the stomach is in consequence quickly exhausted ; the peristaltic action of 
the walls of the stomach is often very vigorous, and may give rise to the 
regurgitation of the food swallowed, especially as the cardiac sphincter is 
weaker and more easily gives way in infants than in adults. 

The part which the stomach plays in the digestion of milk during infancy 
has been much discussed. To what extent is it simply a reservoir in which 
curdling takes place, digestion being performed in the intestines ? Does 
it perform the double function of reservoir and play an important part in the 
digestion of proteids ? Under normal circumstances there can be little 
doubt that some of the curd of milk is converted into peptone in the stomach, 
while a varying amount passes on into the intestines unchanged. Proteid 
digestion is continued in the intestines in an alkaline medium, and a certain 
portion appears to escape altogether, and is passed in the faeces. Under 
abnormal conditions, as when the infant is fed on cow's milk, or is overfed, 
by far the major part of the curd passes out of the stomach unchanged, to 
be attacked by the juices of the intestines, but much escapes digestion, and 
is passed per rectum. Both the juices of the stomach and intestines are 
easily exhausted by overfeeding, and fermentative changes take place, and 
decomposition products are formed instead of peptones. Coagulation of 
milk takes place in the stomach through the agency of a ferment in from 
10 to 15 minutes, which is independent of the acid or pepsin. Human milk 
coagulates in fine flocculi ; cow's milk, especially if undiluted, in heavy dense 
masses. In young infants taking human milk gastric digestion is complete 
in an hour and a half or thereabouts, the stomach being empty, but a longer 
time is required for the stomach to get rid of a meal consisting of cow's 
milk. Observations have shown that the hydrochloric acid secreted is 
absorbed by the proteids, and it is only towards the end of digestion, when 
the stomach has passed on most of its contents, that free acid can be detected. 
Lactic acid does not appear to be a normal constituent of digestion, but it is 
common enough as a product of fermentation. 1 

For the first few months the diastatic ferments of the pancreatic and 
intestinal juices are exceedingly feeble, so that starches are not digested, 

1 See Disorders of Digestion in Infancy and Childhood, by W. Soltau Fenwick, M.D. 



A limen tary Canal — Urine 



7 



while, on the other hand, the trypsin of these secretions is active from the 
first. The secretion of bile begins at an early period of fcetal life, probably 
about the third month ; the bile accumulates in the small intestines and is 
passed as the meconium during the first few days after birth. It forms dark 
brown or greenish masses, viscous and tenacious, and of a feebly acid re- 
action, and consists of mucus holding in suspension fatty matters, epithelial 
cells, biliary pigments, and cholesterine, but no bile-acids. Three or four 
days after birth the meconium is succeeded by the golden yellow semi-liquid 
stools characteristic of the healthy infant. This yellow colour is due to the 
bili-rubin of the bile ; the green colour sometimes seen in intestinal catarrh 
depends upon the oxidation of the bili-rubin and formation of bili-verdin. 
Under normal circumstances newly born infants have two or three stools 
daily. Their character gradually changes as the infants get older, becoming 
more and more like the stools of adults. 




Fig. i. — Stomach of a Newly Born Infant (natural size). 



Urine. — The newly born infant generally passes water within 24 hours 
of its birth, and continues to do so some 10 or 12 times daily, passing about 
1 oz. at a time, or about 10 oz. in 24 hours. The first urine passed is cloudy 
from the presence of uric acid and epithelial cells, and is of specific gravity 
1003-1006 ; later it becomes clear and of a light straw colour. It contains 
more uric acid and less urea (about -5 per cent.) than does that of adults. 

During the whole of childhood the urine is of a paler colour, has a more 
decidedly acid reaction, and lower specific gravity (1012-1015) than during- 
adult life (1018-1020) ; smaller quantities are also passed, but on account of 
the difficulty of collecting the total quantity the amounts have not been ac- 
curately determined. The following figures may be taken as approximative : 

Between 2-5 yrs. about 15-25 oz., containing 5-14 grammes of urea (in 24 hrs.) 
5-9 ,, ,, 25-35 » -. I 4~ I 9 

9-J4 -- -■ 35-40 - .. 19- 22 

5° .- .. 30 



Adults 



While actually smaller quantities of urine are passed by children than 
adults, yet relatively the amount is greater ; the observations of Carriere 
and Monfit l have shown this and also that the amount of solids, total N, 
1 Presse mddicale, 21 Juillet, 1897. 



8 The Physiology of Infancy and Childhood 

and urea per kilogramme of bod) weight is more during childhood than in 
adult life. The same observers found the amount of uric acid actually and 
relatively less in amount. 

The amount of urea excreted per kilogramme of body weight is as 
follows : 

15 mths. to 5 yrs. . *6i grammes 10 yrs. to 15 yrs. . -49 grammes 
5 yrs. „ 10 yrs. . '65 „ Adults -40 „ 

Temperature. — The temperature of an infant at birth taken in the 
rectum is about ioo° F. (3775 C, Roger, Sommer). A few minutes after 
birth it sinks to 97°, or in weakly infants still lower ; in the course of a few- 
hours it again rises and remains at about 98-8° F. This temperature or a 
fraction of a degree higher — 98*8-99° F. — may be taken as the normal rectal 
temperature during childhood and youth. For young children, if exact 
observations are required, the rectum is the best place to insert the thermo- 
meter, as it is difficult to keep the infant quiet with a thermometer in its 
axilla. It is important to remember that the rectal temperature exceeds 
that of the axilla by about 7 F. For most clinical observations the fold of 
the groin or the axilla may be taken. What is also of importance is the time 
at which it is taken. According to the careful researches of Finlayson, the 
diurnal range of temperature amounts to about 2° F., the maximum being 
at 5 to 6 P.M. and the minimum in the small hours of the morning ; the range 
of temperature in adults being somewhat less. According to Reitz, the lowest 
temperature is between 4 and 5 a.m., increasing to n a.m., falling to 2 p.m., 
then rising to its diurnal maximum at 6 P.M. 

The most recent observations upon the temperature of children in health 
were made by the late Dr. O. Sturges. The most interesting of these were 
made upon two sturdy children living in the country, aged respectively 1 year 
and 2 years. The temperatures were taken at various hours from 10 A.M. to 
midnight, the usual range being 97*4 to 98-6. The highest temperature was 
after breakfast, when the children were most lively and eager for play. 

The heat of the body is maintained with greater difficulty during infancy 
than in later life, a result due not only to the relatively larger surface, but 
also to the much greater vascularity of an infant's skin. Infants and children 
are much more liable to suffer from cold extremities than are adults. 

Nervous System. — The closure of the anterior fontanelle takes place to- 
wards the end of the second year in strong and vigorous children ; in immature 
and rickety children it may be delayed till the third year, or it may be later. 

The circumference of the head averages at : 

Birth 14 inches 2 years 20 inches 

6 months .... 16^ „ 4 „ 21 „ 

12 „ 18 „ 10 „ 21} „ 

The cubic capacity of the skull in newly born infants is about one-third 
that of adults, viz. 500 c.c. ; by the second year it is about 1,000 c.c, while 
in the adult it is about 1,500 c.c. The brain of a newly born infant forms 
about 14 per cent, of its body weight, while in the adult it is only 2-37 per 
cent. The brain doubles its weight during the first year of life— 14 oz. to 
28 oz. — by the seventh year it has reached 38 oz. ; by the fourteenth or 
fifteenth year 42 oz. to 45 oz. ; the average brain weight of an adult (male) 



Nervous System — Sight — Hearing 9 

being about 50 oz. The cerebellum after birth develops more quickly than 
other parts of the brain, the frontal lobes more slowly till six years of age, 
when they develop rapidly. 

If the brain of a newly born infant be examined, it will be noted that its 
consistence is much less firm than is that of an adult's, and it is much more 
readily injured. If placed on a plate it spreads itself out or moulds itself 
into any shape more readily than an adult's brain. The pia mater is ex- 
ceedingly delicate and very easily dissected off with a pair of forceps. In 
colour the brain is light grey, often yellowish from the presence of bile pig- 
ments ; there is no well-marked difference between the ' grey ' and ' white ; 
substance as in adult brain, and the convolutions are less distinctly marked. 
The multipolar cells in the grey matter on the surface are ill developed, as 
also is the pyramidal bundles of nerves which connect them with the basal 
ganglia and internal capsule ; on the contrary, the nerve elements of the 
cord and spinal nerves are well developed. 

From the above facts it is clear that while the excito-motor centres in the 
spinal cord and medulla are well developed at birth, the higher centres — the 
' think-organs ' — on the surface of the brain are imperfect, and so also are the 
strands or nerve-paths which connect the higher and lower centres. This 
agrees also with the experiments of Soltmann, who has shown experi- 
mentally that the application of some form of irritation, as the induced 
current, to the surface of the brains of newly born animals does not evoke 
movements in the face and limbs as it does in adults. The actions of infants 
— sucking — crying — swallowing — breathing — are reflex, and inasmuch as 
they are uncontrolled by the inhibitory influence of the higher centres, are 
apt to be disorderly and excessive ; as, for instance, in convulsions. The 
reflex actions displayed by a brainless frog are more violent and vigorous 
than those displayed when the brain is intact. The readiness with which 
the newly born infants become convulsed is one of the most remarkable fea- 
tures in early life. Hereditary influences play an important part, infants 
coming of a neurotic stock being much more prone to convulsions from 
slight exciting causes than others. As the higher centres develop, changes 
come over the mental character of the infant, and the reflex actions become 
more and more under control and dominated by the psychical centres. The 
movements of newly born infants are almost entirely reflex, though certain 
' spontaneous' or ' impulsive ' movements, such as stretching the limbs, occur. 

Sight. — In the first week after birth the infant apparently cannot distin- 
guish objects, but can light from darkness. According to Preyer's examina- 
tions, the movements of the eyes are not co-ordinated at first. Konigstein, 
from an examination of 300 newly born infants, states that they were all 
hypermetropic. The colour of the iris is bluish-grey or green, but one finds 
also shades of light grey and brown. The same investigator has also noted 
blood extravasations in the retina, which disappear in a few days. The pupils 
are very large in the newly born, and sensitive to light ; in later child- 
hood they can endure strong light better than can adults. Of the colours, 
children learn first to distinguish white from black ; in the second year they 
learn to distinguish other colours, first red and yellow, later green and blue. 

Hearing-. — In the newly born the mucous membrane of the tympanum is 
swollen so that no cavity is present, consequently they are not very sensitive 



io The Physiology oj Infancy and Childhood 

to sounds, but shrill and strong sounds make impression, the infants waking 
with cries. In the first months children hear high and sharp sounds better 
than deep. Older children can hear very weak and high sounds which 

make no impression on adults. 

Taste. Newly boni infants can distinguish sweet, bitter, sour, and salt 

Psychical Phenomena.- In the second month an infant learns to hold 
up its head and make voluntary movements and to distinguish the voices of 
its friends. At the 3rd or 4th week it can laugh, and smiles when caressed. 
In the 3rd to 4th month the infant notices its toys or anything it can hold in 
its hands, mostly putting them to its mouth. At 7 to 9 months the child can 
sit up, and 3 or 4 months later makes attempts to walk ; when a year old 
well-developed children can walk a few steps without help. From this time 
tlie child begins to say a few syllables, such as td-td, dd-dd, be-b£, without 
much notion of applying them ; then words are learnt, and by the end of 
the second year most children can string a few words together. 1 

Sleep. — The newly born infant sleeps all day except when it wakes up 
for food. At a year old the infant sleeps fifteen to sixteen hours ; from 2 to 3 
years, twelve to thirteen hours ; from 4 to 5 years, no sleep in the day, 
from ten to twelve hours at night ; from 12 to 13 years, eight to nine, hours. 
Infants sleep lightly and are easily awakened ; at 4 to 5 years of age they 
arc generally heavy sleepers. 

Body Weight. -An infant born at full term weighs from 6£ to 7^ lb., 
7 lb. being an average weight. For the first two or three days of life there 
is a loss of 4 oz. to 7 oz., then a regular gain, so that by the 8th or 9th day 
the initial loss has been made good. According to Gregory, the following 
figures express the average daily loss and gain during the first six days of life : 

1 st day . . loss of 139 grammes or nearly 5 oz. 

2nd „ „ 64 „ „ 7,\ „ 

3rd „ . . gain of 33 „ about 1 „ 

4th „ 50 „ „ if „ 

5th „ 50 „ „ 1 1 „ 

6th „ . „ 36 „ „ 1^,, 

That these figures are by no means universally correct is clear from the 
difference in weight noted by different observers ; thus, according to Lewis 
Smith, in 170 infants born in the New York Infant Asylum (89 male and 81 
female), the average weight of the boys was 7 lb. 11 oz. and the girls 7 lb. 
4 oz. Fifty of these were wet-nursed, and weighed when one week old, with 
the following result : 

Increase of weight in . 

Loss ....... 

Average gain 

„ loss ..... 
Greatest gain ..... 

„ loss ..... 

1 For an account of the development of the aifant's mind, sec Health in (he Nursery, 
Longmans & Co. 



32 


cases 


13 




11 


4 


8 


oz. 


3 


3 


» 


12 




it 


6 




M 



Body Weight 



i i 



Growth during the first year, more especially during the first six months, 
is extremely rapid, the infant doubling its weight in the first six months and 
trebling it during the first year. Many observations have been made on the 
weights of children during the first year ; the following" table exhibits the 
monthly gains, being the average of nine infants observed by W. Pfeiffer, who 
were nursed at the breast at first, and later this was supplemented with cow's 
milk : 

Monthly gain. 



Age. 



i st month 

2nd „ 

3rd „ 

4 th „ 

5th „ 

6th „ 

7th „ 

8th „ 

9th „ 

loth „ 

nth „ 

1 2th „ 



Weight at end of the months. 



oz. 

26 
21 
21 

17 
21 

23 
20-1 

11 



lb. 
8 


oz. 

5± 


10 


4 


11 


15 


13 


9i 


14 
16 


Hi 

-,1 

J2 


17 
18 


5 
10 


20 


1 


21 


Si 


22 





22 


7 



MANCHESTER 

CHILDREN'S HOSPITAL. 

lbs. 



Name- 



Date of Birth 

Weight at Birth- 
Notes of Food, &>t. 



CHART TO SHOW INCREASE IN WEIGHT DURING THE FIRST YEAR. 



AGE IN WEEKS. 

20 24 28 32 36 



11^. 















■ „ . tl 


r £ 


^Z 








. S 


*r 


^ 7 


-->*- 


~7 


A- S 


S 


■*? - 


S 






S 


^ ~ 


- _j_. « _ 


„3^ - . 




^." 


^ 




. ... . 




^ 




^ »» "" 1 



















DOTTED LINE SHOWS AVERAGE WEIGHT AT 



36 40 

IFFERENT AGES. 



Fig. 2.— Weight Chart, showing normal weights during first year. The infant's weight 
"can be filled in with ink or pencil every week. (Reduced size.) 



The Physiology of Infancy and Childhood 



Growth after the end of the first year is slower, so that the weight is not 
again doubled till the end of the sixth year, and doubled again by the end of 
the fourteenth. 

During health it will be often enough to weigh the infant once a week. 
It is convenient to record the weight on a chart such as the one figured 
(fig. 2) ; the ( hart can be fitted into a case and hung up in the nursery. 

Mik h interest and importance is attached to the increase of weight and 
height during infancy and childhood : weekly weighings, especially during 
the early months of life, give very valuable information with regard to diet. 
It must, however, be always borne in mind that increase in weight, especially 
if it be due to an accumulation of fat, does not always indicate strength, or 
that the food being taken is a suitable one. During childhood, undergrowth 
or loss of weight must be looked upon as an indication of danger and as evi- 
dence of malnutrition. On the other hand, overgrowth without a proportionate 
increase in weight should always be taken as indicative of weakness. 





Fig. 3. — Jaw of a Child at Birth, showing the Dental Sacs (Quain's ' Anatomy '). a, the 
left half seen from the inner side ; b, the right half seen from the outer side ; the hone 
has in part been removed to expose the dental sacs, b shows the sacs of the temporary 
set and the sac of the first permanent molar behind the posterior molar of the milk set. 
a shows the same, and also the sacs of the permanent incisors and canine. 

It is not only of interest, but it is important, to both weigh and measure 
children at frequent intervals. Periods of under or over growth are periods 
of danger, as indicating either malnutrition or an overtaxing of the strength. 
There should also be maintained a close relation of height to weight. 

Dentition. — At birth the jaw contains the dental sacs with the already 
calcified crowns of the temporary teeth. Besides the temporary teeth, there 
is the calcified crown of one of the permanent set, the first molar, which is 
situated immediately behind the last temporary molar. (See fig. 3.) 

During the interval which elapses between birth and their eruption, the 
teeth are undergoing further development ; the sacs become enlarged, so that 
they are readily felt through the gum as rounded swellings, the edges of the 
teeth become sharper, and the fangs are developed. As the fangs elongate, 



Dentition 



13 



the edge of the tooth comes nearer to the surface of the gum, the latter swells 
and becomes more vascular, the edge of the tooth appears as a line or point 
beneath the membrane, which finally becomes perforated, and the tooth is cut. 

The temporary set appear for the most part in groups in the following 
order. First group — The lower two central incisors appear from the 6th-8th 
month, followed by a pause of from three to six weeks. Second group— The 
four upper incisors are cut at intervals of a week or two, from the 8th-ioth 
month, followed by an interval of one to three months. Third group — The 
lower lateral incisors, the upper and lower front molars appear at intervals 
from the 12th- 14th months, followed by a pause of two or three months. 
Fourth group — The canines appear, the upper ones usually being first, from 
the i8th-20th month. Fifth group — The posterior molars mostly appear 
at the age of 2-2^ years. 

The milk set, when complete, remain unchanged for several years, though 
the permanent set are gradually becoming developed in their sacs, ready to 
replace the earlier set. 




Fig. 4. — Lower Jaw of a Child of about three years, showing the relation of the temporary 
and permanent teeth. The milk teeth of the right side and incisors of the left are shown, 
and also the sacs of the permanent set, except the wisdom tooth, which is not yet formed. 
The large sac near the ramus of the jaw is that of the first permanent molar, and above 
and behind it is the rudiment of the second molar. (Quain's ' Anatomy. 5 ) 



The following formula exhibits the relation between the temporary and 
permanent set : 

mo. ca. in. in. ca. mo. 
(Upper 2 1 2 1 2 1 2 =10) 

Temporary set-J .—_____. _.._ l 20 



Permanent set-: 



Lower 




2 


I 


2 


1 2 


1 


2 


= 10 




mo. 


bi. 


ca. 


in. 


in. 


ca. 


bi. 


mo. 


Upper 


3 


n 


1 


• 2 


2 


1 


2 


3-i6 



( Lower 



2 I 



1 2 3 = i6j 



At six years of age there are a greater number of teeth in the jaws than 
at any age, there being the milk set and all the permanent set except the 
wisdom teeth. 

It is to be particularly noted that during this period a marked increase 



14 The Physiology of Infancy and Childhood 

takes place in the length of the jaw to provide room for the three molars of 
the permanent set, which make their appearance posteriorly to the milk set ; 
the bicuspids replace the temporary molars see fig. 4). 

While the above account represents the state of things which obtains 
under normal conditions, yet important deviations both as to the time of the 
appearance of the teeth through the gum and the condition of the teeth 
themselves frequently take place as the result of disease or enfeebled nutri- 
tion. It is well known that rickets is the most common cause of delayed 
dentition, and not only are the teeth cut later than usual, but the defective 
nutrition which exists in this state frequently interferes with the develop- 
ment of the teeth ; they may in consequence be dwarfed or provided with a 
thin or partially deficient layer of enamel, so that they quickly become carious 
after being cut. 

The jaw of the infant at birth contains the calcified crowns of all the milk 
teeth and also the calcified crown of one of the permanent set, namely, the 
first or ' six-year-old ' molar, which commences to calcify during the sixth 
month of intra-uterine life. The calcification of the permanent incisors 
commences when the infant is about a month old, the canines at 3 or 4 
months of age and the bicuspids later, in the first or second year. The 
crown of the second permanent molar begins to calcify during the fourth or 
fifth year, but the wisdom tooth not till about puberty. 

It is plain, therefore, that any illness occurring during the first year, such 
as syphilis, can only affect the calcification of the incisors, canines, and 
possibly the bicuspids. (See Second Dentition, p. 63.) 

The permanent teeth are cut in the following order : 

Molar, first ..... 6 years of age 

Incisors, central .... 7 „ „ 

„ lateral .... 8 „ „ 

Bicuspid, anterior .... 9 „ „ 

„ posterior . . . . 10 „ „ 

Canines ...... 11-12 „ „ 

Molars, second . . . .12-13 » » 

11 third 17-25 „ 

Mortality in Infancy and Childhood. — In this country, out of every 
1,000 children born, on an average 149 die before the end of their first year 
of life, and 263 before the age of 5 years. During the next five years, from 
5 to 10 years of age, 35 die, and 18 more between the ages of 10 and 15 
years. So that out of the original 1,000, 684 will be alive on their fifteenth 
birthday and 316 will be dead. From these figures it is clear that the 
mortality is the greatest during the first year, and that it rapidly declines as 
childhood advances. Indeed, the mortality is the greatest during the first 
day and succeeding days after birth ; thus Korosi, in analysing the ages of 
infants at death, found, out of 26,623 infants born in Pesth during the 
years 1874 and 1875, tnat out °f every 1,000 born, 13 died within 24 hours ; 
57 on the second day ; 34*2 during the first week ; 26-3 during the second 
week ; and 92 during the first month. 

1^ appears that infant mortality is slowly decreasing in this country, 
though at a much slower rate than adult mortality. Thus in England and 



Mortality in Infancy and Childhood 15 

Wales the mortality during" the decades 1851-60 and 1861-70 was equal to 
154 per 1,000. In the years 1871 80 it declined to 149, while in 1881-90 
it was 142. 

The mortality of infants differs enormously, and is dependent upon the 
amount of care which is taken in their feeding, and the way in which they 
are looked after, as well as upon their parentage. Roughly speaking, it may 
be said that among the rural population of Great Britain, and among the well- 
to-do dwellers of suburban districts, the annual infant mortality amounts to 
100 per 1,000, 900 out of every 1,000 children born being alive at the end of 
the first year. This is the average infantile death rate of Norway, which is 
the lowest of any European country, and, indeed, probably in the world. 

In a large city, such as Manchester or Liverpool, the annual death rate 
among infants under a year is 200 per 1,000 births, or, in other words, one- 
fifth of those born never reach the end of their first year. In the worst and 
most crowded districts there is little doubt that the mortality is at least 300 
per 1,000, one-third of those born never living to become a year old. A still 
higher death rate prevails among the unfortunate class of illegitimate chil- 
dren ; the mortality among these amounts at times in some districts of our 
large cities to 500 per 1,000, not more than half living to be a year old. In- 
deed, the mortality has in some districts of Salford risen to 710 per 1,000.' 

In London the rate of infant mortality is about the same as that of the 
country generally, namely, 150 per 1,000. The mortality is the same in 
Paris as in London, while in most Continental cities it is higher. In 
Munich (1884-1889) it averaged 324 per 1,000 ; in Berlin, 268 per 1,000 ; in 
Russia, 266 ; and in Austria, 255 (Rahts). 

As one would naturally expect, child mortality also differs greatly under 
different circumstances ; thus we find in the healthy parts of England rhe 
annual mortality of children under five years of age is not more than 50 per 
1,000 (living at that age), that is, out of every 20 children (under five years 
of age) only one will die during the year ; whilst in the worst districts 100 
or even 1 10 per 1,000 perish annually. 

Child mortality is also slowly decreasing in this country. During the 
ten years 1861-70 the mean annual death rate of children under five years 
of age was equal to 68*6 per 1,000. During 1871-80 it fell to 63-5 per 1,000 ; 
while in 1881-90 it fell to 56*8 per 1,000. This, however, is just twice the 
mortality given by Ansell's tables, which are based on the experience of 
child life among the upper classes, namely, 28*2. 

Of the causes of death in these cases, it may be taken for granted that 
diseases of the digestive system play a most important role ; but statistics 
are more or less untrustworthy, as the causes of death which appear on death 
certificates are often not to be relied upon for purposes of classification. 
Analysing the causes of death from 2,000 cases of infants under two years 
of age, who died while under the care of the medical officers of our own 
Children's Dispensary, we found that of the fatal cases those connected with 
the digestive system head the list, forming 35 per cent, of the total number. 
Bronchitis and its allies caused death in 21 per cent, of the cases ; whooping 
cough in 12 per cent. ; congenital syphilis in 10 per cent. ; and measles in 
9 per cent. 

1 See Dr, John Tatham's Health Reports for Salford. 



[6 The Physiology of Infancy and Childhood 

Among the less frequent causes of death we find tuberculosis, meningitis, 

diphtheria, and various malformations. We must not forget to mention that 
premature birth accounts for some deaths that do not figure in our list, and 
those unfortunately too common cases which are returned as ' found dead 
in bed.' 

Infant mortality should not be calculated, as is sometimes done, by com- 
paring infant deaths with deaths at all ages, or with the number of persons 
living, inasmuch as in a given population there may be many or few children 
or few old people, but it should be calculated on the infant population, or 
the number of children living at that age. Thus the number of deaths in 
infants under a year old should be compared with the number of infants 
living at the time, which is usually calculated as the mean of the births 
in that and the preceding year. In the same way the mortality of children 
under five years is calculated by comparing the deaths in the year with the 
number of children living under five years of age. 



CHAPTER II 

THE DISEASES INCIDENT TO BIRTH 

There are certain lesions which can occur only once in a lifetime, inasmuch 
as they owe their origin to the act of birth, or to those important changes 
which occur in the life conditions of the infant when it exchanges the quiet 
dependence of intra-uterine life for the greater activity of an independent 
existence. Though many of these morbid conditions differ from one another 
in various ways, yet they are so intimately associated in their pathology and 
etiology that it is most convenient to discuss them together, rather than to 
relegate them, as is often done, to their respective places in the ordinary 
classification of disease. The act of birth brings its own special dangers to 
the infant as well as to the mother, and it is hardly surprising to find that 
many perish on the threshold of life, and that the mortality during the first 
few days after birth is greater than that of any other period. It must also be 
borne in mind that parturition is not only responsible for many infant deaths, 
but for damage done to the nervous centres by pressure or haemorrhage, 
which may be irreparable, and if the infant lives it is paralysed for life or a 
hopeless imbecile. These diseases which are connected with parturition 
are also of much interest and importance, in that many of them are eminently 
preventible, and are often the result of the ignorance of the friends or neigh- 
bours, who, in the absence of a medical practitioner or trained nurse, preside 
in the lying-in room, or may possibly be the result of ' meddlesome mid- 
wifery.' However this may be, many a life is lost and various morbid con- 
ditions arise for want of assistance during the later stages of labour, or for 
the want of care and cleanliness, or from exposure to contagion during the 
first few days which succeed birth. We will first consider the effects of 
asphyxia, so common in newly born infants. 

Asphyxia Neonatorum. — It is hardly to be expected that the transition 
from placental to pulmonary respiration should be accomplished without some 
risk of the cessation of the one before the commencement of the other. 
Fortunately for the infant, as we have already remarked, its nervous centres 
and tissues generally are far more tolerant of a venous condition of blood than 
they are in after life, for during intra-uterine life the aeration of the blood is 
far less perfectly performed by the placenta than it is afterwards by the lungs, 
and, moreover, there is a mixture of the placental blood with the venous 
blood of the inferior vena cava before it is distributed to the body, {a) The 
infant may die from this cause before birth, or it may be born asphyxiated ; 
(&) asphyxia may supervene after birth through failure of the pulmonary 
respiration. 

c 



i 8 The Diseases incident to Birth 

(a) Asphyxia befoic birth is caused by the death or faintness of the 
mother, detachment of or interference with the placental circulation, or 
compression of the cord. Asphyxia of the foetus may be suspected if the 
fcetal heart becomes faint, the pulsation of the cord ceases or is weak, or it 
meconium is passed. In infants born asphyxiated the symptoms vary 
according- to the degree of asphyxia present ; when slight, the lips are of a 
bluish tint, the skin dusky, the conjunctivae injected, the limbs are motion- 
less, but the muscular tonus is present, the heart's action is slow and mostly 
visible, the movements of respiration are separated by long intervals, or no 
attempts are made unless some strong reflex irritation is applied. In the 
deeper stages of asphyxia the face and lips are pallid, the extremities blue, 
the muscles of the limbs and neck have lost their tonus, no attempts are 
made at respiratory movements, or only a few inspiratory efforts accom- 
panied by indrawing of the ribs and epigastrium, but without any effect in 
expanding the lungs. 

(d) Asphyxia after birth is in rare cases the result of a haemorrhage into 
the fourth ventricle or medulla, and thus the respiratory centres are paralysed 
(Horrocks). In others, mucus or liquor amnii has been sucked into the air 
passages during the act of birth, or a haemorrhage has taken place into the 
lungs through pressure (Spencer). Among the rare causes, asphyxia maybe 
due to an imperfect development of the diaphragm, double pleuritic effusion, 
syphilitic infiltration of the lungs, and pressure on the trachea from enlarged 
glands. The commonest cause, however, is weakness or immaturity of the 
infant ; its ribs are wanting in rigidity and its inspiratory forces feeble, so 
that it fails to draw in air with sufficient power to inflate the lungs ; as a 
consequence the lungs remain to the greater part of their extent in the fcetal 
or unexpanded state, a condition to which the term ' atelectasis ' is applied. 
Those infants who have some complete physical obstruction to the entrance 
of air into the lungs necessarily only survive their birth a few minutes ; 
either no attempt at respiration is made or inspiratory efforts are accom- 
panied by recession of the chest walls, without any air entering the chest. 
Premature or weakly infants may survive for many hours or even days with 
a large portion of their lungs in an unexpanded state. They are extremely 
feeble, their cry is weak and whimpering, their lips and limbs are dusky 
blue, and their temperature below normal. Their respiratory movements 
are confined to slight contractions of the diaphragm, sometimes accompanied 
by indrawing of the walls of the chest ; they have hardly strength to suck, 
and are in a drowsy or semi-comatose condition. They frequently suffer 
from local twitchings, less often general convulsions. If they live over 
forty-eight hours they become jaundiced and the limbs cedematous. An 
examination of the bodies of such infants reveals the usual signs of death from 
asphyxia : the blood is dark and fluid ; the right heart and veins distended : 
the sinuses and membranes of the brain congested and a meningeal 
haemorrhage may be present. The lungs will be found in a condition of 
atelectasis or pulmonary apoplexy. In a case which we recently examined 
in which the infant died six hours after birth, both lungs sank in water, were 
solid everywhere except at the anterior edges, where there were clusters of 
air-containing lobules of a light red colour, scattered over the surfaces of the 
ripper lobe. The cut sections displayed purple solid lung without a trace of 



Asphyxia Neonatorum 19 

expanded lobules, a condition due probably to a pulmonary apoplexy occur- 
ring during birth. In another case, where the infant lived three days, the 
lungs and heart together just floated in water, but the lungs everywhere had 
a solid feel, crepitating very slightly ; the surfaces of both lungs were covered 
with distended lobules, while the central parts were solid. As a rule, 
the upper lobes are more often expanded than the bases, and the anterior 
and inferior edges and surfaces more than the central parts. Care must be 
taken not to confound atelectasis of the lung with pneumonic consolidation ; 
the latter condition is rare in the newly born. 

Treatme?it. — 1. Remove any mucus or fluid from the fauces and air- 
passages by means of the finger or by suction with a soft india-rubber catheter 
Inverting the body may be useful. 

2. Attempt to excite respiration by some form of irritation applied to the 
skin. Fanning the face or directing a current of air by means of a pair of 
bellows is often of use. This may also be effectually done by placing the 
infant in warm water (ioo° F.), and then dashing cold water over it by means 
of a sponge or the hand, or by slapping it with the wetted corner of a towel. 
or, if the faradic current is at hand, a feeble current may be applied to the 
diaphragm and other inspiratory muscles. 

3. If these methods fail, no time should be lost in directly inflating the 
lungs by a soft catheter passed into the larynx or by Richardson's bellows, 
or by practising artificial respiration by Sylvester's or Schultz's method, 
which is to be continued as long as the cardiac sounds can be heard. 

Active treatment will less often be required in those cases of asphyxia 
supervening after birth from non-expansion of the lungs. Gentle measures 
may be undertaken to excite more active respiratory effects, and to combat 
the somnolence by means of hot and cold water, or by the application from 
time to time of stimulating liniments to the chest. Such infants, however, 
but feebly respond to our efforts, and over-treatment in this direction may 
easily do more harm than good ; our efforts will mainly have to be directed 
to placing the infant under the most favourable conditions for gaining strength 
and gradually bringing about expansion of the lungs (see p. 58). 

Apoplexia Neonatorum. — Cerebral haemorrhage occurring in early life 
is hardly ever the result of a ruptured artery, but is almost invariably caused 
by a venous congestion, and takes place from the capillary vessels of the pia 
mater or choroid plexuses. The arteries of the young are not liable to suffer 
from atheroma, but retain their elasticity, and, moreover, are not likely to have 
to submit to any unusual strain from an hypertrophied heart. On the other 
hand, the pia mater in early infancy is exceedingly delicate and its capillaries 
fragile ; this can be readily demonstrated by noticing how easily it is stripped 
from the brain by means of dissecting forceps, and how loose is its connection 
with the soft brain substance beneath it. Further, we have already alluded 
to the fact that the cerebral sinuses and veins become distended with blood 
in asphyxia from various causes — a rupture of the capillary vessels of the 
pia mater takes place, and blood is effused into the sub-arachnoid space. 
This effusion, in consequence of the loose connection of the pia with the 
brain, may extend over a large surface, or burst into the sub-dural space. 
The blood clot may compress or lacerate the brain substance, and if the 
infant lives for a few days it may be followed by softening. The haemorrhage 

c 2 



20 



The Diseases incident to Birth 



may take place during birth, from compression of the umbilical cord, producing 
asphyxia, and is consequently especially common in breech presentations ; 
or it may result from pressure on the head by the uterus or the blades of the 
forceps (Spencer). We must bear in mind that the pia mater is not only 
very delicate and its capillaries easily ruptured if they are over-distended, 
but also that a stasis is very apt to occur in the superficial veins on account 
of their peculiar connections. Cowers has laid stress on the fact that here 
ascending arteries pass into ascending veins, and, moreover, these surface 
veins empty themselves into the superior longitudinal sinus in a forward 
direction and consequently against the blood current. Thus the Sylvian 
vein commences in the fissure of that name and courses upwards to empty 
itself into the superior longitudinal sinus, receiving the small veins from the 




Fig 5. — Meningeal Haemorrhage in an Infant ; death on the twenty-second day. 
(After McNutt.) 



motor area en route. Near its commencement the Sylvian vein has con- 
nections with the superior petrosal sinus (Trolard) and also with the basilar 
vein. 

Spencer l comes to the conclusion, as the result of an examination of the 
bodies of 130 infants born dead or dying soon after birth, that pressure on 
the skull by the forceps or the uterine walls plays an important part in pro- 
ducing meningeal haemorrhage. He believes that when the bones of the 
skull are abnormally soft and the sutures lax, the lower edge of the parietal 
bone may press on the Sylvian vein or its connections, when the head is 
subjected to severe pressure during labour, and thus a haemorrhage in the 
Rolandic area may be produced (fig. 5). He also thinks that clamping of the 

1 Obstetrical Transactions, vol. x>xiii. 



Apoplexia Neonatorum 21 

internal jugular by the forceps or pressure on the infant's neck by the 
parturient canal may give rise to congestion and meningeal haemorrhage. 
It would appear from the observations of Spencer, that, while these cerebral 
haemorrhages are most common in severe and instrumental labours, they 
are not unknown in labours that are short and easy. The infant may live 
some days after the haemorrhage has taken place, as in a case recorded 
by McNutt ; the labour, which was a breech presentation, was easy; the 
breathing became irregular on the day of birth ; later it suffered from con- 
vulsions, difficulty of swallowing, left hemiplegia, and emaciation. It died on 
the twenty-second day. At the post-mortem the right hemisphere was covered 
by a clot (see fig. 5), which was firm and gelatinous, and of a dark colour, 
the convolutions beneath it were in part destroyed, especially so in the ascend- 
ing frontal and parietal regions. The clot also invaded the brain substance, 
actually forming part of the roof of the ventricle, whilst the site of the corpus 
striatum and optic thalamus was occupied by a reddish-brown clot mixed with 
softened brain tissue. This case is remarkable as showing how long an 
infant may survive an extensive cerebral haemorrhage and the further damage 
by the secondary inflammatory softening which evidently took place. 

These are instances of fatal cases, but there is good reason to believe 
that such cases frequently survive, and bear for the rest of their lives traces 
of the damage done to their brains at birth. It is not difficult to imagine 
the damage which a surface haemorrhage may do. It may lead to com- 
pression of the convolutions, or meningitis, or softening, or it may more 
likely lead to atrophy, or interfere with the development of the convolutions. 
Such a case, verified by post-mortem^ has been recorded by McNutt. The 
infant was born with the feet presenting, the labour was tedious, and there 
was delay in disengagement of the head. Convulsions supervened, lasting 
for some days ; the child never walked or spoke ; there was spastic paralysis 
of both sides, except the face ; it died at two and a half years. Atrophy of 
the convolutions about the fissure of Rolando was found at the post-mortem. 
Similar cases are tolerably common ; there is a history of a difficult labour ; 
the infant is blue, and perhaps is thought by the midwife to be dead ; it may 
be convulsed, but recovers. There is probably no marked paralysis at first, 
but after a few months it is noticed that an arm or a leg, or both legs, are 
weak ; then contractions take place, the legs becoming adducted, with the 
toes pointing, the forearms supinated, and the elbows more or less fixed 
(see Birth Paralysis). The intelligence is often affected, and the child is 
late in talking. 

Haemorrhages into other Viscera. — Spencer found in his post-mortem 
examination of stillborn children haemorrhages into the lungs, liver, kidneys, 
intestines, testis, &c. In the lungs the most frequent site was the base, the 
appearance being that of ordinary pulmonary apoplexy, the haemorrhagic 
portions being solid and of a black red colour on section. If the infant 
lives pneumonia may arise. Haemorrhage taking place into the kidney may 
cause death during the first few days of life by suppression of the urine 
(Spencer). Haemorrhage into the bowels may cause obstruction. 

Cephalhematoma. — During birth a haemorrhage may take place from 
the vessels of the periosteum of the skull, and a collection of blood form 
between that membrane and the bone ; more rarely a haemorrhage occurs 



22 



The Diseases incident to Birth 



between the occipito-frontalis aponeurosis and the periosteum, or between 
the skull and the dura mater. The name ' cephalhematoma externum ; is 
applied to the first two, thus : 



Cephalhematoma externum 

„ internum 

Meningeal haemorrhage . . 



ji. Sub-aponeurotic. 
(2. Sub-periosteal. 

3. Sub-cranial. 

4. Sub-arachnoid. 



In the common form the tumour is sub-periosteal. The swelling, 
occupying a position immediately over a parietal bone, generally the right, 
is usually discovered for the first time a day or two after birth, when the 
swollen and distorted head of the infant should begin to assume a more 
natural shape. According to the statistics of Hennig and Hofmokl, a cephal- 
hematoma occurs about once in every two hundred births ; in one hundred 
and twenty-seven cases noted by Hennig, it was situated fifty-seven times 

over the right parietal bone, thirty- 
seven times over the left, twenty- 
one times over both, seven times 
over the occipital, three times over 
the frontal, and twice over the tem- 
poral bone. It forms a more or 
less tense elastic tumour, neither 
hot nor tender, and it does not 
extend beyond the limits of the 
bone over which it is situated, inas- 
much as the periosteum is firmly 
attached to the sutures. The scalp 
is not discoloured. The tumour 
varies in size from a walnut to a 
small orange, increases in bulk for 
a few days after birth, and then 
begins slowly to diminish. After 
it has existed for a week or two, 
a ridge of bone may generally be felt at its circumference, where new bone 
has been thrown out by the periosteum (see fig. 7 c'). When the tumour is 
examined for the first time in this stage, it is apt to give the impression that 
there is a circular defect in the parietal bone, through which a fluid tumour 
is protruding. At times, especially in chronic cases, thin plates of bone form 
here and there in the periosteum forming the roof of the tumour and give 
rise to a feeling of crepitation when it is handled. In the course of a few 
weeks or a month the tumour shrinks and disappears, leaving for perhaps 
many months a more or less complete bony ridge, which marked the circum- 
ference of the tumour. The etiology of these blood-swellings is not very 
clear, but, like other haemorrhages which take place during birth, they owe 
their production in part to asphyxia, in which there is increased tension in 
the cranial veins, and a condition of blood which readily allows of extravasa- 
tion. From the fact that the tumour mostly occurs at the site of the caput 
succedaneum, being over the right parietal bone in nearly three-fourths of 




Fig. 6. — Double Cephalhematoma in an Infant 
twenty days old (from a photograph). Labour 
difficult, forceps applied, right facial paralysis. 



Cephalhematoma 23 

the cases, it would appear that pressure upon the head played an important 
part in its causation ; but, on the other hand, cases are reported in which a 
blood-swelling appeared over a parietal bone in a case of breech presen- 
tation (Runge, McNutt). Small extravasations, the size of a pea or a 
shilling, may frequently be seen beneath the periosteum in making post- 
mortems on newly born infants. If the caput succedaneum be incised, the 
tissues immediately beneath the scalp will be found infiltrated with a jelly- 
like effusion with numerous minute haemorrhages scattered through it, and 
on examining the parietal bone numerous small haemorrhages may be seen 
beneath the periosteum, some linear in shape, corresponding with the lines 
or foramina in the bone situated near the inter-parietal suture or posterior 
fontanelle. According to Fere the edges of the foramina play an important 
part in wounding the vessels during labour, and producing a haemorrhage, 
as they are the means of transmitting small veins from the scalp to the 
cerebral sinuses. It is important to bear in mind that not infrequently an 
effusion of blood external to the skull communicates with an effusion of 
blood between the bone and dura mater through one of these openings, and, 
further, a meningeal haemorrhage may also take place. 




Fig. 7. — Section of a Cephalhematoma (semi-diagrammatic), Hennig. a. Dura mater ; 
b, parietal bone ; c, periosteum ; c', ossification of ditto ; d, scalp ; e, blood clot. 

The diagnosis is not generally a matter of difficulty. A blood tumour 
beneath the periosteum is distinguished from a caput succedaneum, inasmuch 
as the latter does not fluctuate, disappears in a day or two, and extends 
beyond the limits of a parietal bone. It is distinguished from a meningocele in 
that the latter corresponds to a suture or fontanelle, pulsates, and increases in 
size when the infant cries. Very rarely a blood-swelling takes place beneath 
the scalp, between the latter and the periosteum. In such cases the scalp is 
discoloured, no bony ring would be formed, and the swelling might extend 
beyond the sutures. The prognosis as far as a cephalhaematoma is con- 
cerned is favourable, but inasmuch as it is possible that it is complicated by 
meningeal or extra-dural haemorrhage the prognosis must be guarded, and 
any brain symptoms are necessarily of evil omen. 

Treatment. — The treatment of these blood swellings has been much 
discussed. On the one hand, it has been urged that if the cephalhaematoma 
is subperiosteal, it should be aspirated without delay while the blood is 
fluid and before coagulation has taken place, as in this way the long delay 
during which absorption and deposition of bone are taking place is avoided. 



24 The Diseases i)icident to Birth 

On the other hand, it has been pointed out that it is never possible to tell if 
the blood swelling does not communicate with a blood extravasation within 
the skull, thus rendering surgical interference risky, and moreover that 
although absorption of the effused material may be tardy, it is both safe and 
sure, and a good result may be confidently looked forward to. The latter 
course is certainly to be recommended ; surgical interference in a newly born 
infant always has its risks, there is always the possibility of introducing 
septic organisms into the blood swelling by aspiration, and at the most all 
that is to be gained by such a proceeding is the saving of a few weeks of time. 
We believe that all cephalhoematomata are most safely let alone, care being 
taken to protect them from injury ; small ones may be shaved and painted 
with collodion, or during sleep some spirit lotion may be kept applied. In the 
.rare event of their suppurating the treatment would be that of an ordinary 
abscess — viz. evacuation of the pus and drainage. 

Haematoma of the sterno-mastoid. — If an attempt be made by an un- 
skilful midwife to disengage the after-coming head by pulling on the legs or 
body of the infant, there is a strong probability that injury will be done to 
the neck or other part, especially as the muscles of the semi-asphyxiated 
infant are flabby and toneless, and the blood readily oozes out of the vessels. 
Such an injury does at times take place, giving rise to a blood tumour within 
the sheath of one of the sterno-mastoids in consequence of the tearing through 
of some of the fibres of the muscle or injury to some of its vessels. The 
swelling appears to be actually composed at first of blood and of the retracted 
torn muscle, later no doubt of inflammatory material resulting from the injury, 
and in some cases where a permanent thickening remains it is due to cica- 
trised tissue round the torn and retracted muscle. Thus we have seen the cla- 
vicular part of the muscle torn away from its attachment, and a swelling at the 
junction of the two bellies. It is not often that an opportunity occurs of veri- 
fying this condition post mortem, inasmuch as no serious consequences arise 
from the accident, but the investigations of Tordeus, Spencer, and others 
make it clear that these swellings are due to local injuries at birth. In one 
of our own cases in which the infant died of diarrhoea when six months old, a 
cicatrisation of the muscle at the spot where the injury had taken place was 
found. In another case we had also the opportunity of a post-mortem. At 
least three-fourths of these cases are breech presentations : in the remaining 
fourth, which occur in head presentations, the injury is no doubt caused by 
dragging on the head in order to disengage the shoulders and body. The 
swelling in the neck may be noticed by the mother a few days after birth, or 
it may escape observation for some weeks, or even more. On examination 
a tumour about the size of a pigeon's egg may be felt in the upper part of the 
right sterno-mastoid ; it is generally irregular, or perhaps elongated, in shape, 
and if not seen for some time after birth, when cicatrisation has taken place, 
it is hard and cartilaginous to the touch. The left muscle is less often injured 
than the right ; sometimes the whole length of the muscle is affected, though 
the lesion is generally in the upper part. The tumour disappears in the 
course of a few months, but for a long time a cicatrix may be felt. There is 
no treatment required. These cases mostly occur among the poorer classes, 
who are attended in their confinements by neighbours or unskilled midwives. 
Injury to the sterno-mastoid during birth derives its importance from the 



Occipital Hcematoma 25 

fact that such injury is likely to be the cause of wry neck in after life (see 
Torticollis). 1 

Occipital Hematoma. — Injury to other muscles may occur during birth, 
and we have seen in one case a ' tumour' in connection with the muscles at 
the back of the neck arising from injury during birth. It was a head presen- 
tation, and there was also a sterno-mastoid ' tumour.' The child was seen at 
five weeks old. Labour had been prolonged, head delivered by forceps with 
much difficulty, and subsequently severe traction was needed to extract the 
body. Two symmetrical swellings were felt in the muscles at the back of the 
neck, evidently due to hematoma. There was left facial paralysis and para- 
lysis of the left arm. The child was heard of two years later, and it was said 
to have completely recovered. 

Obstetrical Paralyses. — In cases of delayed labour, where the forceps 
have to be applied, or where force is used to disengage an arm or traction 
is applied to it, some nerves or strands of nerves are apt to be injured either by 
stretching, direct pressure, or compression by extra vasated blood. The most 
common and best known is an injury to one of the facial nerves through pres- 
sure exerted by one of the blades of the forceps during extraction. A facial 
paralysis is thus produced, which as a rule is temporary, and disappears in a 
few days or weeks. The other and less common form, which has been de- 
scribed by Duchenne as ' obstetrical paralysis,' is due to an injury of one or 
other of the cords of the brachial plexus, produced by the pressure of the finger 
hooked in the axilla in order to extract the arm and shoulders, or the arm has 
been forcibly wrenched when it has been used to lay hold of to drag the infant 
through the pelvis. Occasionally an injury may be done to the brachial plexus 
as well as to the facial by the grip of the forceps blades, as in a case recorded 
by Roger, where the face and arm were paralysed. After death an effusion 
of blood was found at the stylo-mastoid foramen, and also round the cords of 
the brachial plexus. The cord most often injured is apparently the fifth cer- 
vical nerve, which, as Ross has snown, is readily injured, at the point where 
it descends over the transverse processes of the fifth and sixth cervical ver- 
tebras on its way to join the brachial plexus, by force applied to the arm or 
clavicle. The prognosis in paralysis of the arm from a lesion of the brachial 
plexus is more serious than it is in paralysis of the face, but it will neces- 
sarily vary according to the amount of injury done and the degree of para- 
lysis present. The symptoms presented by this form of paralysis may be 
illustrated by the following cases which came under our notice. 

In the first case, the head, according to the mother, was born first ; there 
was then a delay ; finally the left arm was disengaged by the finger hooked in 
the axilla, and the child born after some delay and difficulty. The infant was 
first seen when seven weeks old. At this time its arm hung uselessly by its 
side, the elbow extended, the humerus rotated inwards and adducted, the 
forearm pronated, the hand closed (in some cases the hand is open, the palm 
turned backwards on account of the supination of the forearm), the paralysed 
muscles being the biceps and brachialis anticus, the infraspinatus and teres 
minor, the deltoid and supinators. The muscles affected were soft and flabby. 
The arm was regularly galvanised, the faradic current being used. Three 

1 See also D'Arcy Power, Med.-Chir. Trans, vol. lxxvi. who gives a list of cases from 
Clutton and others' observations as well as his own. 



26 The Diseases incident to Birth 

years afterwards great improvement had taken plaee ; the elbow could be 
flexed and the hand could be used, but a paresis remained of the deltoid and 
supinators. In another case, seen first at ten weeks of age, the same muscles 
were paralysed, much improvement took place, but the infant died at six 
months old of bronchitis. In a third case, which was a footling, the left arm 
engaged the pelvis with the head, and had to be brought down by the 
accoucheur. The arm was noticed to be bruised and useless after birth. Un- 
fortunately this case was lost sight of. In another case seen by us, both arms 
were almost completely paralysed, only the fingers in one hand retaining some 
power of flexion. The mother had a contracted pelvis, the head presented, 
the medical man turned and delivered with much difficulty ; there was also a 
sterno-mastoid hematoma. In two cases reported — one by Seeligmuller, the 
other by Thorburn — the paralysis was more extensive than in the above cases ; 
there was also retraction of the eyeball and contraction of the pupil of the 
same side. Probably there was here a more severe injury, involving the 
whole brachial plexus and also the sympathetic. In some cases a temporary 
anaesthesia has been noticed. In the treatment of these cases it must be 
borne in mind that one or more of the cords of the brachial plexus has been 
injured, accompanied by a local haemorrhage ; and therefore, the more at rest 
the arm can be kept for the first few weeks the better. It seems doubtful if 
any shampooing or galvanising of the muscles can at first do much good. 
The treatment must be rather that of a fractured bone — rest at first, and 
afterwards more or less active movement to exercise the muscles and prevent 
stiffness. The arm should be carefully wrapped up in cotton wool, flexed and 
supported by being fixed to the side, care being taken to prevent undue 
disturbance during the daily bath, or allowing it to hang down and drag on its 
connections with the trunk. It must be borne in mind that the circulation 
of blood will be sluggish, and easily obstructed by tight bandaging. At the 
end of three weeks, when there is reason to believe that absorption of the 
effused blood has taken place, movements of the arm may be begun, in order 
to give the muscles some exercise and to call forth the voluntary efforts of 
the child. Galvanism, shampooing the muscles, applying stimulant applica- 
tions to the skin, must be persevered with as long as any improvement takes 
place. The prognosis in the severe cases is gloomy as far as the paralysed 
muscles are concerned ; the arm remains in a condition of extension and 
pronation, and is unable to be raised to the mouth. In other cases, as in 
the one mentioned, recovery takes place sufficiently to allow of flexion of the 
elbow, though a certain amount of weakness may be left about the shoulder 
and in the supinators of the wrist. The biceps usually is the first to recover, 
while the deltoid and supinators are the last, if indeed they recover at all. 

Icterus Neonatorum. — Infants often suffer from a more or less pro- 
nounced jaundice which comes on a day or two after birth. It has been 
estimated by Continental writers that this occurs in from 60 to 80 per 
cent, of the total births ; but these observations have been mostly made in 
lying-in hospitals, where it appears to occur much oftener than in private 
practice, though there is little doubt that on account of the slightness of the 
yellow coloration of the skin, and the frequent absence of discoloration of 
the sclerotic, it may easily be overlooked. Jaundice may arise from or be 
symptomatic of various pathological conditions, the principal during the first 



Icterus Neonatorum 27 

week of life being the following : 1. The common form in which no disease 
is apparent — icterus neonatorum. 2. Jaundice accompanying a condition 
of septicaemia or pyaemia ; in acute fatty degeneration of the newly born ; 
in Winckel's disease. 3. Jaundice due to congenital stricture, or oblitera- 
tion of the common or hepatic duct, or to syphilitic perihepatitis. The 
common form to which the name of ' icterus neonatorum ' is generally 
applied differs from the other forms in not being accompanied by any serious 
symptoms, and in passing off in a few days or a week. In these cases the 
yellow coloration of the skin makes its appearance on the second day, less 
often the third, rarely either before the second or after the third, and lasts, 
according to its intensity, from two or three days to a week. The yellowness 
is first noted on the face, around the mouth and chest, then on the abdomen, 
later on the limbs ; it may be easily overlooked, unless pressure is made by 
the finger on the skin. In mild cases the sclerotics remain unaffected, and 
the urine does not stain the linen ; this is the more noteworthy, as in the 
jaundice of adults the sclerotics are affected before the skin is tinged, and 
pigment is very early present in the urine ; probably the vascularity and 
transparency of the infant's skin account for the difference. When the 
jaundice in the infant is more intense, the sclerotics become tinged ; the 
urine stains the diapers, and bile pigment may be detected. The stools are 
unchanged and contain the usual quantity of bile. In cases which die when 
suffering from this form of jaundice, the internal organs are found stained 
yellow, especially the cartilages, the brain, and in a lesser degree the abdo- 
minal viscera. The majority of infants who are jaundiced appear in perfect 
health ; it has, however, been asserted by Hofmeier that infants with icterus 
do not flourish as well as other infants, that their loss of weight during the 
first week is greater than that of healthy infants, and that a higher per- 
centage of urea and uric acid appears in the urine. The cause of this form 
of jaundice is uncertain ; it is much more frequent in lying-in hospitals 
than in private practice, and in premature weakly infants with partially 
expanded lungs than in full-time and healthy infants. There have been 
many hypotheses concerning its cause, but none of them are entirely satis- 
factory. One of the most plausible explanations has been suggested by 
Quincke ; he attributes the jaundice to the ductus venosus remaining patent, 
thus allowing some of the portal blood (which contains bile pigments) to pass 
into the general circulation, instead of all of it being submitted to the action 
of the liver. Virchow and others believe it to be a haematogenous jaundice, 
the bile pigment originating in a destruction of blood corpuscles which it is 
supposed takes place shortly after birth. 

While this form of jaundice xs per se a symptom of little importance, and 
in the vast majority of cases the infants do well, it is well to remember that 
occasionally cases occur which are jaundiced shortly after birth, and which 
die about the ninth or tenth day without any definite disease being discover- 
able. These cases sometimes occur in the same family, as in the following 
remarkable instances : the father and mother were both healthy and in 
comfortable circumstances, there was no history of syphilis, the first and 
second children were never jaundiced, and are at present alive and well ; the 
third, fourth, fifth, and sixth children became jaundiced on the second or 
third day, and died on the ninth or eleventh day. In all, the skin and con- 



28 The Diseases incident to BirtJi 

junctivae were jaundiced, the urine contained bile pigment, the stools were 
normal. The fifth child was seen with Mr. G. H. Pinder, their medical 
attendant, when five days old ; it seemed a perfectly healthy infant, except 
that it was jaundiced. The infant became weaker and drowsy, and died 
comatose on the ninth day. A partial post-mortem only was obtained ; the 
abdominal viscera were bile-stained ; the ductus venosus was only partially 
closed ; there was nothing abnormal about the bile-ducts. What is the 
nature of these and similar cases it is at present impossible to say. We have 
seen several other similar cases, where infants have become jaundiced 
shortly after birth and died in a few days without any apparent explanation. 
The diagnosis between icterus neonatorum and the jaundice which accom- 
panies septicaemia does not present much difficulty, for in the latter case 
there would be some suppuration or phlebitis of the umbilical cord or ecchy- 
mosis and various haemorrhages. In acute fatty degeneration and Winckel's 
disease there are usually cyanosis, purpuric spots, and haemorrhages. In 
jaundice from obstruction of the ducts, the jaundice is intense and bile is 
absent from the stools. Nothing much can be said about the treatment of 
infantile jaundice, which consists rather in attending carefully to the general 
health of the infant than in the administration of any special drug. Small 
doses of hyd. c. cret. may be given for its laxative effect, and to relieve any 
tendency to mechanical congestion of the liver. 

Hemorrhagic Diathesis. Haemophilia Neonatorum. — It not infre- 
quently happens that within a few days of birth the infant exhibits a tendency 
to bleed. There may be haemorrhages from the nose, stomach, bowels, 
or kidneys, and petechiae and ecchymoses may make their appearance on the 
skin. Oozing of blood, which is perhaps difficult to arrest, may take place 
from the navel on the separation of the cord. This tendency to bleed is no 
doubt to be looked upon as rather a symptom than a disease or the result of 
disease. It cannot be said that our knowledge is very exact regarding the 
conditions which give rise to the haemorrhagic diathesis in infants, but in a 
large majority of cases at least the infant is either syphilitic or suffers from 
septicaemia or from both conditions. The poisons generated by the syphilitic 
or septic infection appear to cause such changes in the blood as give rise 
to bleeding on the slightest injury. In some of the cases in which there was 
no evidence of syphilis during life, the evidence has been forthcoming at the 
post-mortem, and, moreover, syphilis is not disproved by no lesions being 
discovered in an infant a few days old. 

In seven cases recorded by Fischl 1 in which haemorrhages took place 
shortly after birth from the mucous membranes or into the skin, there was 
evidence of syphilis ; there being characteristic rashes on the skin, enlarge- 
ment of the spleen, and interstitial hepatitis. In one of the authors 
cases, however, the only evidence of syphilis was the enlargement of the 
spleen and an interstitial hepatitis. A careful microscopical examination of 
the minute blood-vessels was made in these cases, with the result that they 
were found normal, so that the bleeding could not be attributed to arteritis. 

In three cases of haemophilia in infants recently investigated by H. 
Neumann 2 pyogenic organisms were found, and the author inclines to the 

1 Archiv fur Kinderheilk. Band viii. 
2 Ibid. Bande xii. xiii. 



HizmorrJiagic Diathesis — Hemophilia Neonatorum 29 

belief that the entrance of the septic organisms into the system either before 
or during the act of birth had much to do with the haemorrhagic state. In 
the first case the infant, which was illegitimate, suffered from jaundice, petechias 
on the skin, melaena, and hasmatemesis ; it died on the fifteenth day. The 
autopsy showed there had been capillary bleeding from the mucous mem- 
brane of the alimentary canal, enlargement of the spleen, and interstitial 
hepatitis (syphilitic). A bacteriological examination of the blood showed the 
presence of the Bacillus pyocyaneus /3. In a second case, undoubtedly 
syphilitic (snuffles and rash), which suffered from bleeding from the nose and 
mouth, and which died when seven weeks old, a bacteriological examination 
showed the presence of pus cocci, namely, Staphylococcus pyogenes aureus 
and albus and also Streptococcus pyogenes. In a third case, in which the 
mother suffered from syphilitic ulceration of the labia, the infant suffered 
from jaundice and various haemorrhages, and died on the ninth day. Both 
bacilli and cocci {Bacillus pyocyan. /3 and Staphyloc. pyog. aureus) were 
found in the blood. It is not easy to say in the present state of our know- 
ledge whether the bacilli and cocci found were accidentally present, or 
whether they were directly or indirectly the cause of the blood change which 
gave rise to the blood extravasations. The bacilli may enter the fcetal tissues 
before birth through the placental circulation or be inoculated at the time of 
birth or afterwards through the navel. 

Acute Fatty Degeneration of the Newly Born. — Buhl, in 1861, de- 
scribed the symptoms and morbid anatomy of a rare disease, occurring in 
newly born infants, to which he gave the name of acute fatty degeneration. 
His observations have since been confirmed by Hecker, Furstenburg, Rolofif, 
and Runge, though it cannot be said that this condition is sufficiently well 
known for it to take its place as a well-defined and definite disease. The 
infants suffering from it are generally born in a condition of asphyxia with- 
out obvious cause, and some die asphyxiated. If they survive, they usually 
suffer from more or less cyanosis, with haemorrhage from the bowels, 
stomach, or from the navel on the separation of the cord. There is often 
jaundice, and blood extravasations take place beneath the skin, conjunctiva, 
or mucous membrane of the mouth ; there may be general oedema ; death 
usually takes place within two weeks. At the post-jnortem minute haemor- 
rhages are found in the various internal organs, which are sometimes infil- 
trated with blood ; the tissues are bile-stained. On microscopical examina- 
tion of the tissues of the heart, liver, kidneys, &c, they are found to be in a 
condition of fatty degeneration. The nature of the disease is quite unknown. 
It is interesting to note that a similar condition has been observed in newly 
born pigs and other domesticated animals. 

Winckel's Disease. — A disease somewhat similar to the last has been 
described as occurring in an epidemic form by Winckel, and is characterised 
by cyanosis, jaundice, and haemoglobinuria. This epidemic occurred in the 
Foundling Hospital at Dresden in 1879, where twenty-three infants were 
affected in the course of a month. The symptoms noted were first of all a 
bluish tinge on the skin of the face, body, and limbs, with a more or less 
icteric tint ; in some cases there were vomiting and diarrhoea. The urine 
was of a light brown colour, with a sediment consisting of epithelium and 
casts ; the blood contained an excess of white corpuscles and many granular 



30 The Diseases incident to Birtli 

bodies. The symptoms usually began on the fourth day after birth, death 
occurring in one case in nine hours, though the average duration of the 
disease was about two days. The sections showed a yellow staining of the 
skin and internal organs. The spleen was large and hard and dark red : 
the kidneys were usually dark brown in colour, the microscopic examination 
showing their tubules to be filled with granular pigment. There were puncti- 
form haemorrhages on the surface of the various internal organs, and fatty 
degeneration of the liver and heart. 

Gastro-intestinal Haemorrhage. — The vomiting of blood, or its passage 
per anum, is not an uncommon occurrence in the newly born. The most 
common cause, especially of haematemesis, is the swallowing of blood oozing 
from a cracked nipple, which the infant sucks, or from some wound in the 
infant's mouth or nose. Large quantities of blood may be swallowed in this 
way, and vomited in a more or less altered condition, or passed as blackish 
masses with the faeces. A haemorrhage may have taken place into the 
bowel during labour and the blood passed in the stools. A much more 
serious condition exists when the source of the bleeding is a small ulcer or 
ulcers in the stomach or duodenum, which may open a large vessel and 
cause fatal haemorrhage, as in a case recorded by Goodhart and another by 
Sawtell. Neumann has recorded a somewhat similar case in an infant 
born of healthy parents, which died on the third day from birth after 
vomiting blood. At the post-mortem an ulcer was found in the duodenum. 
In the majority of cases the bleeding appears to be capillary, due to a 
tendency to haemophilia, which has been described (p. 28). The haemorrhage 
in most instances comes on within the first twenty-four hours ; if the 
amount of blood lost is large, the infant quickly becomes pallid, the skin 
cold, the fontanelles depressed, and convulsions probably follow. Death 
usually takes place within twenty-four hours of the commencement of the 
symptoms ; if the infant survives this period and no fresh attack comes on, 
there is reason to believe there is no lesion of the stomach or duodenum, 
and there is good hope that the infant may survive. The treatment would 
naturally depend upon the diagnosis as to the cause. Small doses of 
ergotine (quarter grain to half grain), in syrup, by the mouth or sub- 
cutaneously, would be the most likely to be of service. In any case of 
passage of blood per rectum in an infant, the possibility of an invagination 
of the intestine must be borne in mind. 

Haemorrhage from the Genital Organs. — It sometimes happens that 
there is a small oozing of blood from the vagina during the first few days 
succeeding birth, sufficient to stain the napkins. The blood may often be 
seen oozing from the vagina, while no lesion of any kind can be detected. 
The discharge lasts for a few days only, generally from two to five, the health 
of the infant does not suffer, and recovery seems always to take place. 
Cullingworth has collected thirty-two such cases, two of which came under 
his own observation. He agrees with Cameron in believing that the bleed- 
ing is due to a congestion of the pelvic veins, the result of the cessation of the 
circulation in the umbilical arteries when the cord is tied. As already stated, 
there is sometimes a coincident discharge of blood from the rectum, due 
apparently to the same cause (see also p. 21). It must not be forgotten that 



Diseases of the Navel — Umbilical Polypus 31 

cases of precocious menstruation may occur, commencing shortly after 
birth, and continuing monthly afterwards. 

Diseases of the Havel. Separation of the Cord. — Under ordinary 
circumstances the umbilical cord shrivels up and drops off at a period after 
birth varying from the first to the fifth day, thin small cords drying up and 
separating earlier than large soft ones (Bouchut) ; the cicatrix is not usually 
dry and firm until the tenth or twelfth day. 

Umbilical Polypus. — Occasionally, after the cord has separated, a small 
red prominent projection is left with a moist surface, and sometimes (Holmes) 
a fine central canal ; this ' polypus ' is the result in most cases of incomplete 
withering of the cord, at other times the outgrowth is rather of the nature of 
a simple granulation polypus from irritation, the so-called ' fungus of the 
navel.' The projection, when small, is often hidden by the overhanging 
skin of the part, and may remain for weeks or months, giving rise to slight 
discharge from the scar and perhaps excoriation of the skin around. In 
another class of cases, such as one sent to us by Dr. Serra, of Eccles, the 
proximal part of the cord instead of 
shrivelling up remained as a red vascu- 
lar projection some three inches long. 
On examining this child some five or 
six weeks after birth, there was a red 
fleshy prominence then about 1^ inch 
long projecting from the navel ; it was 
about as thick as a cedar pencil, and 
its surface appeared to be a mucous 
membrane except at one spot where a 

patch of delicate CUticle was found. The Fig. 8.— Section of Ileo-umbilical Diverticulum. 

apex of the protrusion was perforated ^SEmTn^STX; f^2£*& 

by an Orifice which readily admitted of the everted portion of mucous membrane ; 
j- 1 j ,i_ c, tubular glands; d. remains of muscular 

an ordinary probe, and the instrument c ^ ats . ^ se< ? tion of ' blood-vessels ( x 4 ). The 

COUld be passed downwards in the muscularis mucosae layers are also seen. (Dr. 

middle line and swept round on each 

side for some three inches ; it could only be passed upwards for about half an 
inch. A thin watery mucus in small quantities was discharged, but no faeces 
or urine. Subsequently faecal matter escaped from the orifice. The pro- 
truded mass was ligatured and removed with a good result. This condition 
is due no doubt to persistence of the vitelline duct in the proximal part of the 
cord and its conversion into intestine ; it communicates with the ileum by 
means of Meckel's diverticulum. After the distal part of the cord has 
become detached the end cicatrises, and a prolapse takes place of the whole 
thickness of the tube ; hence in the section in fig. 8 two layers of mucous 
membrane with an intervening muscular and fibro-cellular layer are seen. 
Such cases are not rare ; we have met with several, in which the ' protrusion ' 
was not so large as in the above case, but from which there was a thin 
biliary discharge. A section after excision showed traces of muscular fibres 
and columnar epithelial cells. We have seen a similar case in a child of six 
years old, but the parents declined any interference. 

Another form of umbilical fistula is that due to persistence of the urachus. 
In such cases, sometimes called navel urachus nstulae, urine escapes 




32 The Diseases incident to Birth 

externally at the umbilicus. Sir T. Smith, Mr. Bryant, Mr. T. Paget and 
others have described instances of this deformity which may sometimes be 
cured by ligature. An imperfect obliteration of the urachus may also give 
rise to the formation of a cyst in the middle line of the abdomen below the 
umbilicus. 

The treatment of these affections is very simple : for the larger ones a 
ligature should be applied tightly round the base, and the mass cut short 
off; the smaller ones may be snipped off with scissors or rubbed down with 
nitrate of silver, or dusted over for a few days with powdered nitrate of lead, 
which we have found an effectual remedy. It must be remembered that 
there is considerable variation physiologically in the process of separation 
of the cord ; in weakly children it falls off later and the raw surface is slower 
in healing. Where the cord stump is projecting it is liable to be irritated 
by friction and its healing is slow : this is the condition described as 
excoriation. When a sort of ' mucous surface ' remains and goes on dis- 
charging, the so-called Blenncrrhagla exists, while the presence of a thick 
consistent film on the surface of the sore has been described as croupous 
or diphtheritic exudation ; in some instances it is probable that a true 
diphtheritic membrane is formed. 

Where there is any spreading ulceration after separation of the cord, 
infective influences should be looked for ; the mischief may spread super- 
ficially or it may tend inwards and involve the peritoneum. A mere super- 
ficial excoriation of the skin analogous to intertrigo elsewhere is often seen 
in older children as a result of dirt and neglect. It is readily cured by the 
application of boric powder. 

Simple ulceration is never fatal unless it extends deeply ; it should be 
treated by some simple antiseptic powder or ointment, such as boric acid 
or iodoform. 

Omphalitis is a rare condition. W T hen it exists the navel itself and the 
surrounding parts are inflamed and swollen, the wound remains unhealed, 
and the skin around is red, shiny, tense, and painful. The disease may 
spread and involve nearly the whole of the abdomen either superficially or 
throughout the entire thickness of the abdominal wall ; the infant becomes 
very ill, the legs are stiff and drawn up, breathing is thoracic, and small 
abscesses may form and burst from time to time. The disease begins in the 
second or third week of life, and may last for some days or even weeks. 
The prognosis is good if the extent of mischief is small and suppuration 
occurs early, bad if the disease is widespread, and especially if it tends 
inwards towards the peritoneum ; if the navel vessels are involved, general 
sepsis or gangrene is likely to result. The younger the child the greater is 
the danger. 

The cause of this disease is doubtful. Probably it arises from bad 
management of the navel and infection. Fribe believes some cases to be 
syphilitic. Is it possible that some may be instances of sloughing phage- 
dena ? According to Bouchut it is sometimes complicated by bleeding. 
Treatment consists in cleanliness and the application of antiseptic or seda- 
tive lotions. All abscesses should be opened early, and any tendency to- 
gangrene met with stimulants and antiseptics. 

Gangrene of the navel begins either as an ulcer or as omphalitis ; it 



Gangrene . 3 3 

occurs also in cases of cholera infantum ; as a purely local condition it is 
rare, and Wiederhofer believes that it arises from intense omphalitis. Pre- 
mature separation of the cord and irritation tend to produce gangrene. 

The disease usually begins as a blister containing muddy fluid : on 
bursting this leaves an ulcer, or a sore may exist from the first ; the mischief 
spreads rapidly either superficially or deeply ; a bright red zone is seen sur- 
rounding a central slough, which after a time comes away ; there is rapid 
prostration of strength, though but little pyrexia. Recovery from gangrene 
of the navel is rare, though sometimes the slough separates and the cavity 
granulates up ; more often death results from peritonitis or exhaustion, or 
again from gangrene of the bowel and perforation, which is sometimes met 
with ; occasionally a faecal fistula is formed. 1 In many cases general sepsis 
occurs, and Ritter believes the gangrene is merely a result of the septic con- 
dition. In cholera infantum there is sometimes rapid gangrene without any 
sign of reaction, and this may occur as late as several months after birth ; it 
is always fatal. 

The treatme7it of gangrene consists in free stimulation and the use of 
antiseptics ; nitrate of silver, perchloride of iron, and salicylic acid are recom- 
mended by Runge, to whose work, 'Die Krankheiten der ersten Lebenstage, 
we are indebted for nearly all our information on these diseases. Faecal 
fistula, if the child survives, should be treated as in older children. 

Umbilical Arteritis. — In fifty-five subjects of disease of the umbilical 
vessels Runge found fifty-four cases of arteritis, and in only one was there 
phlebitis alone. The mischief begins as inflammation of the cellular tissue 
round the vessels, and then spreads to them, producing thrombosis. Pelvic 
cellulitis, which sometimes occurs, is the result of septic lymphangitis 
spreading directly along the cellular tissue, and is not due to embolism. 
Inflammation in cases of arteritis may spread far and wide from the navel, 
and even reach the bladder or its neighbourhood. Where arteritis exists 
the navel often presents a projecting discoloured ulcer covered with a scab : 
sometimes, however, the scar is healed and quite natural in appearance. 
The disease may arise either before or after separation of the cord, and 
suppuration and sloughing may occur. 

Sometimes the lumen of the arteries is seen open, and the vessels are full 
of pus or breaking-down clot ; suppuration usually spreads along the vessels 
as far as the cellulitis extends, beyond this adherent coagula are found. At 
times the arteries are pouched, and the sacs formed are found full of pus ; 
the intima of the vessels is always dull and has lost its polish. 

The most common complication of the disease is pneumonia ; septic 
inflammatory foci may, however, also occur in the liver, spleen, kidneys, 
peritoneum, bones, and joints, &c. Erysipelas sometimes attacks the part, 
and slight jaundice is common, though severe jaundice with hepatitis is rare. 
Of Runge's fifty-five cases, in nine there was arteritis alone, in sixteen there 
were complications, such as syphilis, 'atrophy,' cerebral haemorrhage, &c, 
and in the remaining thirty cases there were pyaemic lesions. Peritonitis is 
to be suspected as soon as distension appears. Tetanus is an infrequent 
complication. Arteritis is a disease of dirt and neglect ; it occurs in 
epidemics, and is often associated with puerperal fever ; it may be inoculated 
1 In one remarkable case an intussusception occurred through a faecal fistula. 

D 



34 The Diseases incident to Birth 

by the lochia or decomposing umbilical cord, and lias been found associated 
with ophthalmia neonatorum. It usually runs a rapid course, Lasting from 
four to eighteen days, and is especially fatal to young and premature children ; 
in older infants the prognosis, though bad, is not absolutely so ; in fatal 
cases death is usually sudden. 

Umbilical Phlebitis. — As already pointed out, umbilical phlebitis is a 
rare disease. 

The general appearances of phlebitis are very like those of arteritis : there 
is thickening of the perivascular tissue, the lumen of the vein is diminished ; 
it is tortuous and contains pus or sanious material, the intima is cloudy 
and eroded. Usually the whole vein as far as the liver is affected, and there 
may be hepatitis. Peritonitis and intense jaundice are both common. The 
etiology of the disease is the same as that of arteritis. The symptoms of 
phlebitis are fever, icterus, altered respiration, inspiration being short, ex- 
piration prolonged, while the breathing is shallow, frequent, and entirely 
thoracic ; the upper part of the abdomen is tumid, and there is local tender- 
ness, the knees are drawn up, and the child is restless. It is difficult to dia- 
gnose phlebitis from arteritis ; the intense icterus in the former is the most 
characteristic feature. The disease lasts only a few days, and is always fatal 
from general sepsis. The treatment of both arteritis and phlebitis consists 
in the application of salicylic acid or other antiseptic and the use of stimulants 
and free nourishment, together with great cleanliness. 

These diseases appear to be almost unknown in this country at the pre- 
sent day, judging from the absence of any literature, but they are likely to be 
met with in dirty quarters of large towns. 

Umbilical Haemorrhage is to be looked upon as a symptom rather than 
a disease in itself ; it is met with in the shape of bleeding from the umbilical 
vessels themselves, and as a general oozing from the raw navel surface. 

Bleeding from the vessels may occur from slipping or imperfect tying of 
the ligature round the cord ; as, for instance, when a thin ligature cuts into the 
vessels. Bleeding, of course, by no means necessarily follows slipping of the 
ligature, or even failure to tie the cord at all. The aspirating action of breath- 
ing prevents any haemorrhage in most instances, and this is supplemented 
by the contraction of the vessels after birth. 

Asphyxia may, however, produce some escape of blood as the vascular 
pressure rises in slight degrees of suffocation ; in other instances- deficient 
muscular contraction appears to be the cause, hence bleeding is most common 
in premature children who have been asphyxiated or whose lungs have not ex- 
panded. If it arises from imperfect muscular contraction it may occur some 
hours after birth (Hofmann). As the vessels begin to contract at the cord, 
and the obliteration extends towards the hypogastrium, there is more risk of 
bleeding if the cord is cut very short. So, too, drying up of the cord tends 
to obliterate the vessels, while gangrene and swelling tend to prevent their 
closure. Bleeding may also occur later from rough handling of the navel 
and separation of the scab. All danger from this form of haemorrhage may be 
prevented by tying the cord firmly with a broad ligature not too near the 
abdominal wall ; should bleeding occur, pressure or the application of astrin- 
gent powders, a fresh ligature or acupressure will arrest it. 

Idiopathic, or spontaneous bleeding so called, is a very rare occurrence, 



Umbilical Hemorrhage 35 

and its etiology is obscure. Grandidier collected twenty-two cases from 
various sources. The bleeding usually occurs about the fifth day, just after 
or more rarely before the cord comes away, the blood trickles from the 
surface of the umbilicus, and not from any distinct vessel ; the oozing may 
be continuous or intermittent. The subjects of the affection are generally 
healthy full-time children ; there is often, however, slight icterus ; in other 
cases there is some intestinal disturbance, vomiting, colic, &c, with deep 
icterus, cyanosis, and drowsiness before the bleeding occurs ; in any case 
these symptoms appear soon afterwards. Bleeding not seldom comes on 
from the stomach or intestines, or there may be general purpura, and some- 
times there is oedema of the hands and feet together with the umbilical 
haemorrhage. 

The great difficulty or impossibility of stopping the flow is characteristic 
of the condition. Most of the cases die before the second week ; the 
mortality is put down as 83 per cent. The infant usually dies comatose, less 
often in convulsions. 

Umbilical haemorrhage is a symptom of several diseases ; probably in some 
cases, as we have already pointed out, it is due to haemophilia or syphilis. 
Privation, drink, and other depressing causes acting upon the mother are 
also assigned as reasons for it. Septicaemia and ' fatty degeneration of the 
newly born' are causes that have been established by post-mortem evidence. 
The blood in these children does not clot readily. It is said to be a com- 
moner disease in America than elsewhere. 

Pressure by various means, such as pads, filling the navel with plaster of 
Paris, underpinning, &c, maybe tried as means of treatment with some hope 
of success ; caustics and astringents, such as perchloride of iron, do not 
appear to be of much use ; the actual cautery has succeeded. Idiopathic 
bleeding is very rarely met with. Fiirth has, however, collected records of 
some cases ; ] it is sometimes epidemic. Weiss has 31 cases out of 742 
children in one year at Prague. 2 

For other morbid conditions of the umbilicus, see ' Deformities of the 
Umbilicus.' 

Tetanus Nascentium, — This disease is almost unknown in this country 
at the present day, although in past times, when less attention was paid to 
general hygiene in lying-in hospitals, it was common, and sometimes was 
the largest factor in infant mortality ; it was also frequent at one time among 
the negro population in America. The disease is identical with the wound 
tetanus of adults, and is caused by inoculation of the navel with the tetanus 
bacillus. This bacillus, as shown by Nicolaier, is constantly present in the 
superficial layers of the earth, and it gains entrance to the infant's body by 
dirty dressings applied to the navel. The bacillus multiplies in the neigh- 
bourhood of the navel, and a strychnine-like poison is absorbed, which 
gives rise to the muscular spasms. The bacilli may be detected in the pus 
of the navel wound, and if the pus be injected into mice they die with 
tetanic symptoms. (Rosenbach, Peiper.) Tetanus (' nine-day fits ') usually 
appears in the first two weeks of life, most commonly from the third to 

1 Arch. f. Kinderh. Band v. p. 305. 

2 For further details, vide a paper by Dr. Francis Minot in the American Jour, of 
Med. Sci. Oct. 1852. 

D 2 



36 The Diseases incident to Birth 

the tenth day, the limits, according to West, being from the fifteenth hour 
to the fifteenth day. The symptoms are usually acute, the earliest being 
inability to suck from spasm of the facial and jaw muscles (trismus) ; general 
contractions, however, soon occur, the spasms are continuous, but incr< 
in violence at intervals ; in most cases there is no complete relaxation. The 
child often utters a peculiar whining cry, and there is well-marked risus 
sardonicus ; the maximum rigidity is generally reached in twelve hours, and 
the child dies in a fit or becomes comatose. 

The spasms are increased by any exposure to cold and by noise : emacia- 
tion is very rapid, and there is often jaundice. Death usually occurs in one 
or two days ; in rare cases the disease is chronic. Hartigan says the chronic 
form begins with dysentery and coldness and pallor of the skin ; hence it has 
been called ' white lockjaw.' It is attended by wasting and twitchings, and 
was described by Marion Sims as ' Trismoid.' Unlike the acute form, which 
always occurs within the first month of life, the chronic variety may appear 
at any time within six months, and may be a sequel of the acute. 

The disease is readily recognised by the spasms and general rigidity. 

The preventive treatment consists in the most rigid cleanliness in dress- 
ing the navel and the removal of insanitary conditions. Opium, chloral, 
bromide of potassium, cannabis indica, belladonna, and other drugs have 
been occasionally successful ; warm baths sometimes relieve the spasms, and 
spinal icebags are worth a trial ; anaesthetics, such as ether and chloroform, 
are useful to relieve pain and allow the child to be fed, but none of these 
remedies have given any constant good result. Further details of the disease 
and references will be found in the works of Bouchut, Meigs and Pepper, 
Peiper, 1 Baginsky. 2 

Sclerema Neonatorum. — This rare disease is practically unknown outside 
foundling asylums and lying-in institutions, and is by no means common 
under any circumstances. The chief characteristics of the disease consist 
in an induration of the skin and subcutaneous tissues, and marked wasting, 
with an abnormally low temperature. The infants at birth may present 
no abnormality, and in some cases at least are plump and healthy-looking ; 
within a few days of their birth they begin to waste, the temperature 
becomes abnormally low, 83 to 86° F. in the rectum, and the integuments 
become hard and rigid ; the change usually begins in the lower extremities 
and spreads upwards, and involves the trunk, upper extremities, and face. 
In typical instances the skin is of a dirty yellow colour, its surface is hard 
and does not pit, and it cannot be raised from the subcutaneous tissues. The 
surface of the body has a cold feel almost like stone. In some described cases 
the rigidity of skin has been so great that the infant could be lifted by the 
head and heels like a rigid body. On account of the rigidity of the skin of the 
face, sucking is performed with difficulty, and the infant has to be fed with a 
spoon. The prognosis is bad, as such infants almost invariably die in a few 
days. In a typical case investigated by Dr. W. P. Northrup, of New York, 
the microscopical examination of the skin showed nothing abnormal. In a 
case of Dr. J. W. Ballantyne's there was an increase in the number and size 
of the connective-tissue bundles and an atrophy of the adipose tissue. 

1 Deuisches Archivfiir klinische Medicin, Bd. xlvii. H. 1 u. 2. 
: ' Berliner klinische Woe hensc hrift, No. 7, 1891. 



Sclerema Neonatorum 37 

Langer attributes the rigidity of the integuments to solidification of the fatty 
tissues, in consequence of the abnormally low temperature. In one case, 
however, reported by Dr. A. G. Barrs, which he believes to have been of 
this nature, the infant, which was a month old when seen by him, made a 
good recovery. In this case the skin over the buttocks and thighs was hard 
and rigid, and could not be raised from the deeper tissues. But it appears 
to have been red and shiny, and without the cold feel so typical of the 
ordinary cases of sclerema. The pathology of these cases is ill understood. 
It has been suggested with much plausibility that they are akin to myxcedema. 
We have seen a similar case in a girl two weeks old, in which the tissues of 
the back of the trunk, arms, and legs were much indurated, red, and shiny. 
They were too hard to pit with the finger. We think that this case, as also 
Dr. Barrs's, were not identical in nature with those described as sclerema. 
We unfortunately lost sight of our case ; the infant was otherwise apparently 
healthy and thriving. 

(Edema Neonatorum, — Weakly, especially premature, infants are apt to 
be cedematous at birth, or become so soon after. An cedematous condition 
of the skin and subcutaneous tissues differs from sclerema in that the former 
readily pits beneath the finger, and the skin is more or less smooth and 
shiny. It is obvious that oedema may be present in many different condi- 
tions, and it does not in itself constitute a disease. 

Gonorrhoea! Ophthalmia. — Though hardly within the scope of this work, 
mention ought perhaps to be made of the danger to the infant of infection 
by gonorrhceal discharges from its mother at birth or shortly after. The 
most common affection is that of the eyes, in which a virulent purulent 
ophthalmia is produced. The inflammation rapidly spreads to the eyelids, 
and involves the cornea, speedily causing opacity, and if allowed to run its 
course unchecked ending in perforation of the cornea, with escape of the 
contents of the globe and complete shrinking of the eyeball. Many cases 
of total blmdness in children are due to this cause. In any case where there 
is a suspicion of vaginal discharge from the mother, an antiseptic douche 
should be carefully used before the birth of the child, and immediately after 
it is born the child's eyes should be examined and carefully washed out 
with a solution of perchloride of mercury (1-4,000), followed by a douche of 
boric acid lotion. At the least sign of any inflammation the eyes should be 
washed with a solution of sulphate of zinc (2 grains-^j), and unless the 
mischief is at once checked a solution of nitrate of silver (10 grains-gj) should 
be employed once a day, washing out again with a solution of salt directly 
after to prevent too powerful action of the silver. The eyes should be bathed 
every hour day and night with a lotion of boric acid, and the silver repeated 
if necessary. It is only by such means that the eyes can be saved in severe 
•cases. The utmost care must of course be taken to use all applications 
thoroughly and get rid of every particle of discharge, as well as to avoid 
subsequent reinfection. For infantile gonorrhceal rheumatism, vide chapter 
on 'Diseases of the Joints.' 



38 Hie Hygiene and Diet of Infants and Children 



CHAPTER III 

THE HYGIENE AND DIET OF INFANTS AND CHILDREN 

Newly Born Infants. — One of the first cares of the nurse after the navel 
has been properly attended to should be to direct her attention to the 
infant's eyes, carefully wiping away, by means of a soft rag, any mucus or 
vaginal discharge which may adhere, and thoroughly cleansing the eyelids 
with warm water. This is a matter of much importance and should never 
be neglected, for if conjunctivitis or a purulent ophthalmia be set up, much 
trouble may ensue and some time elapse before a healthy state is again 
attained, and the risk of corneal opacities and consequent loss of sight is by 
no means small. The temperature of the room in which mother and infant 
are should be maintained, at least in winter, at 65 °, and means be taken to 
thoroughly ventilate it without producing draughts. 

In giving the infant its first bath — necessary on account of the slimy 

whitish secretion with which the infant is covered— care should be taken 

that it is done before a good fire, and that the water of the bath is not too 

hot ; the temperature should not exceed ioo° F., for the infant's skin is 

tender and easily damaged by prolonged contact with warm water. The surface 

of the infant is well cleansed with flannel and soap while on the nurse's lap ; 

it is then bathed, all soap being removed in the bath. This cleansing 

operation is repeated daily, the genital organs and buttocks requiring 

especial care on account of their becoming fouled by contact with soiled 

diapers ; intertrigo and erythematous eruptions are likely to arise if the 

greatest cleanliness is not practised. Some infants' skins are far more 

tender than others and liable to eczema, and require constant care to avoid 

irritation. Care should be taken in the selection of a soap which is free 

from excess of alkali, such as the best class of pure Castile soaps, all excess 

being removed in the bath. The skin should be carefully dried with a soft 

towel, and some fine dusting powder applied to the folds of the groin and 

buttocks. This may consist of finely powdered maize or oatmeal mixed 

with 2 per cent, of salicylic acid, 5 per cent, of boracic acid or thymol, to 

prevent any tendency to decomposition. Pure boracic acid, as in the 

' Sanitary rose powder,' answers very well, and as it is soluble in water is 

easily removed by washing. The diapers should be of a soft and absorbent 

material ; at least a dozen should be provided for use during the twenty-four 

hours. They are usually made of ' swansdown ' or ' Turkey towelling,' but by 

far the best material is ' Gamgee' or ' Robinson ' tissue, a piece being cut 

in a triangular shape, and the edges run. These are more absorbent than 

the ordinary napkin, and can be burnt when soiled. They can be obtained 

ready made under the name of ' knapkinettes.' l 

1 Southall, Barclay, & Co. 



Newly Born Infants 39 

During the first week a flannel binder is necessary to keep the dressings 
in position, but afterwards binders are best avoided ; at least, nothing tight 
should be applied round the abdomen which would cause discomfort to the 
child by compressing the abdominal viscera. A knitted Shetland wool belt 
is much preferable to the ordinary strip of flannel which is stitched or 
pinned. The cord may be dressed with a pad of wood wool wadding or 
Gamgee tissue. 

It is hardly needful to say that a cot should be provided for the infant 
with a firm mattress protected by a waterproof covering, and under no 
circumstances whatever should the infant be allowed to sleep in bed with its 
parents or nurse ; fatal accidents through suffocation of the infant beneath 
the bedclothes are constantly occurring in consequence of the mother falling 
asleep with her infant in bed with her. 

Clothing-. — All the clothing should be loose, and as far as possible con- 
sist of flannel or knitted woollen material, so arranged that the infant can 
be readily dressed and undressed. The common tendency is to load the 
chest and body with too great an amount of clothes and to leave the arms 
and legs too much exposed. For the latter, long loosely fitting woollen 
drawers coming to the waist should be used, carefully protected by the diapers 
from being wetted. 1 

Infant Feeding- at the Breast. — The natural food of an infant is the milk 
from the breast of its mother, no kind of food being thought of for the first 
eight or nine months of its life. The mother's health may of course sooner 
or later interfere with the performance of this duty to her infant, but it is of 
great importance that it should be attempted, if for only a few weeks or 
months, for to undertake the artificial feeding of an infant from the first is to 
expose it to serious risk. 

The infant should be put to the breast a few hours after birth, after the 
mother has somewhat recovered from the pains and fatigue of labour, and 
has had some sleep. It is of much importance that both mother and infant 
should get as much rest at night as possible, and if the infant frequently 
wakes crying, every means should be taken to hush it off to sleep again, 
and for this a little sweetened water or barley water may be used. It is not 
unlikely that for the first day or two, especially in primiparas, the supply of 
milk will be scanty and the infant will hardly get its full supply ; but tnis is 
a matter of little importance, and it is well not to overload the stomach at nrst, 
but to give it an opportunity of gradually accustoming itself to its new function. 

On the other hand, some recent writers (McLane, Holt) have shown that 
thirst and starvation give rise to a febrile condition to which the term of 
Inanition Fever has been given. In some cases at least where the infant 
has sucked at a dry breast and has had no artificial food or fluid or an in- 
sufficient quantity, the temperature rises to 102-104 on the third day, less 
often the second. The infant is restless, its lips and skin are parched. All 
the symptoms are quickly relieved by its taking freely of breast milk, or fail- 
ing this water or artificial food. A temperature of 106 has been observed. 

From the very first it is of importance to accustom both infant and 
mother to regular times for feeding. After the first two days, every two hours 
during the daytime will be quite often enough for an infant of average weight 
1 See Health in the Nursery (Longman & Co.). 



40 The Hygiene and Diet of Infants and Children 

and strength. A longer interval may be taken in the night, so as to give the 
mother as long a sleep as possible ; nine or ten feedings in the twenty-four 
hours will be sufficient. A strong newly born infant empties the breasts in 
about fifteen minutes, and, during this time, takes from i to \h oz. of milk, the 
total amount taken in the twenty-four hours during the first week being 10 
to 12 oz. The infant's stomach, at this period, being only capable of hold- 
ing about i^ oz. (see fig. i) without marked distension, too rapid filling of 
the stomach with fluid is very likely to give rise to vomiting. It is there- 
fore of importance for the mother to feed the infant slowly, extending the 
time to fifteen or twenty minutes. We must not forget that absorption is 
going on during the time the infant is being fed, in strong and vigorous chil- 
dren, so that it may often happen that such will take more than the above 
amounts without injury. 

The infant's stomach rapidly enlarges, and the secretion of milk increases 
as time goes on ; so that, after the first month, eight nursings in the twenty- 
four hours — that is, every two and a half hours during the day, and a longer 
interval at night — will be enough. From the end of the third month till 
the end of lactation, every three hours will be often enough, some 3 to 6 oz. 
being taken at a time, and some 20 to 40 oz. in the twenty-four hours. 
Six to seven nursings in the twenty-four hours will be sufficient. 

Too frequent nursing is bad for the infant, inasmuch as an overworked 
stomach cannot properly perform its functions, and dyspepsia is only too 
likely to result ; the mother's breasts require an interval of rest, for, if too 
frequently drawn, the milk is apt to be unequal in composition, too watery 
after a long, and too rich and concentrated after a short interval. 

During the whole time the infant is being nursed the health of the mother 
is necessarily a question of the greatest importance, as it is impossible 
for a weakly mother, or one in ill-health, to give good milk. The food which 
she takes and the life which she leads are all-important. Anything causing 
indigestion in the mother will be extremely likely to affect the breast milk 
and disturb the infant's digestive organs. 

Various drugs, such as morphia and Epsom salts, when taken by the 
mother, are excreted in the milk, and may of course affect the infant. Any 
violent emotion, such as a great sorrow or any prolonged anxiety suffered by 
the mother, is very likely to alter the quality of the milk, and the infant con- 
sequently suffers. Indeed, under these circumstances, the milk may cease 
to be secreted, and the infant have to be artificially fed. The mother's diet 
should consist largely of milk, porridge, soups, potatoes, fish, and light pud- 
dings, while beef, mutton, and stewed fruit should be taken in moderation 
She should avoid all highly seasoned foods, and those difficult to digest, such 
as pastry, raw fruit, and uncooked vegetables. Alcoholic liquors are unneces- 
sary, and tea and coffee should be taken in moderation. Exercise in the open 
air is of the greatest importance, but it must be graduated according to 
the strength of the mother. 

Exercise appears to tend to diminish the amount of proteids in the milk, 
and decreasing the amount of butcher's meat taken will tend in the same 
direction. Increasing the proteid element in the food, assuming that the 
extra proteid food is digested, renders the milk richer especially as regards 
the fat. 



Infant Feeding at tJie Breast 41 

The milk of the first few days (colostrum) differs from normal milk in 
that it is of a yellowish colour, is unusually rich in proteids, and has a laxative 
effect upon the infant's bowels. It also contains less sugar than normal milk. 
Microscopically a number of granular corpuscles are seen, which are appa- 
rently epithelial cells undergoing fatty degeneration. In a few days the excess 
of proteid disappears, but it may be a week or more before the milk is nor- 
mal. The changes which occur in the quality of the milk during the lacta- 
tion period depend very largely of course on the health of the mother. 
During the later months of lactation the milk tends to become poorer and 
more watery, with a diminution of the proteids and fat. It must be borne in 
mind how completely the secretion of the milk is under the influence of the 
nervous system, and how, also, it varies from time to time from various 
causes ; and more or less caution must be observed in drawing conclusions 
as to the effect of any one cause on the quality of the milk. 

The occurrence of menstruation in a nursing mother or wet nurse is apt 
in some way or other to alter the secretion of the milk, and the infant, in 
consequence, may suffer from colic, flatulence, or diarrhoea. In many cases 
the infant does not appear to suffer at all, while in exceptional cases the 
intestinal disturbance and loss of flesh are so great that the question of wean- 
ing may have to be entertained. It may happen that the infant may suffer 
a good deal at one period and not at the next or succeeding ones. The 
chemical changes which occur during menstruation have been investigated 
by several observers, but no constant change has been found. In some 
cases the careful observations of Rotch have shown that the milk during 
this period is poorer in fat and richer in proteids, but it is tolerably certain 
that this is not universally the case. Monti found that menstruation exercised 
no constant change or influence on the specific gravity or the fatty elements, 
though in some cases observed by him there was an increase in the quantity 
of fat during the period. 

Wet Nurses. — It not infrequently happens that, if an infant's life is to be 
saved, a wet nurse must be procured. It may happen that a weakly infant 
is deprived of its mothers milk, and a foster mother must be obtained if its 
life is to be preserved. In some cases, perhaps, an attempt has been made 
to feed a young infant on some artificial food, various foods being tried, one 
after another, till severe convulsions or continuous diarrhoea warn the 
attendants that a return to the infant's natural food is the only possible 
resource left. Much has been written about the advantages and dis- 
advantages of a wet nurse. We may say at once that, in our opinion, there is 
not the least doubt that no artificial food yet devised can compare with or 
form a substitute for the milk of a healthy woman. To attempt to bring up 
a weakly infant from the first on artificial food is to expose it to far more 
serious risks than if it is provided with a healthy wet nurse. The younger 
the infant is, the more likely is it to take the breast milk of a wet nurse and 
to thrive on it, or in other words the value of a wet nurse is greatest during 
the first few weeks of an infant's life. To put an infant of three or four months 
of age that has been artificially fed to the breast of a wet nurse is likely 
enough to end in failure. Unfortunately in this country wet nurses are 
difficult to obtain, and when obtained are not always easy to manage in the 
household. At the same time, we are inclined to think that the character of 



4- The Hygiene and Diet of Infants and Children 

wet nurses as a class has often been painted in too black colours ; certainly 
we have known many who have clone their duty to their foster infants in a 
most worth)- and exemplary manner. A difficulty often is presented with 
regard to the nurse's own child ; it is put out to nurse, and is deprived not 
only of its mother's milk, but also of its mother's care, and is only too likely 
to go the way that so many ' out-to-nurse ' babies have gone before. In 
large cities wet nurses are usually obtained at the workhouses, where many 
women go to be confined, and are often glad to escape from the discipline of 
the workhouse, and to obtain a situation in a private family at good wages. 

A wet nurse should not be above thirty-five or below twenty-one years 
of age ; very young wet nurses are especially to be avoided, on account of 
their inexperience and the difficulty in managing them. It is better for the 
nurse's infant to be a month or so older than the infant to be nursed. Great 
disparity of age is an objection, as a nurse who has been confined five or six 
months before is not likely to make a good nurse for a newly born infant, at 
least not for the whole time that the infant has to be nursed ; but such a 
nurse may be employed temporarily in the absence of a more suitable one. 
A disparity of two or three months is no objection, provided the nurse is 
suitable in other ways. A medical examination of the nurse should always 
be made — at least, the medical attendant should satisfy himself that both 
the nurse and her infant are free from disease. There is one advantage in 
the nurse's infant being two or three months old, and that is that time 
would have been afforded for any syphilitic rash to make its appearance on 
the infant, and the infant if strong and vigorous is reliable evidence of the 
good quality of the milk. If possible, an analysis of her milk should be 
made upon several occasions, especially with regard to the amount of fat 
present in the milk. But, in spite of all precautions, we must be prepared 
at times to find that the milk of a wet nurse who in every way appears 
suitable does not agree with the infant, and the only resource is to try another. 
Great pains must be taken in the dieting of the nurse, errors being most fre- 
quent in the direction of overfeeding with too little exercise. Meat once a 
day is enough, beer and porter are best avoided, and exercise in the open 
air must be insisted on. 

No infant suffering from hereditary syphilis should be wet-nursed, on 
account of the risk of its infecting its foster mother. 

Weaning. — The length of time during which the infant takes- its sole 
nourishment from its mother's breast depends upon a variety of circum- 
stances. When the mother remains strong and healthy and has a sufficient 
supply, the time may be extended to eight or nine months, or even more. 
Among the working classes the time is often extended much longer than 
this. Infants who are over-nursed are apt to be fat, but are not necessarily 
strong — indeed, they often appear rickety in a minor degree. In a case re- 
cently coming under our notice, the mother nursed her infant entirely at the 
breast for seventeen months. The child weighed twenty pounds, it showed 
signs of rickets, the epiphyses being moderately enlarged and the ribs 
beaded. An examination of the mother's milk, which was plentiful, showed 
it was poor — the amount of fat (average of three samples) 17 per cent. ; the 
specific gravity was 1031. 

Whenever weaning takes place it is wise to do it gradually, in the first 



Weanirn 



43 



place substituting the bottle for the breast once or twice in the twenty-four 
hours, and carefully watching the result before attempting more than this. 
Gradually artificial feeding may be made to take the place of the breast en- 
tirely. It is well to avoid the hottest weather for this change on account of 
the risks of diarrhoea at this time. 

At any time during the period of lactation it may be necessary, on 
account of the mother's health, to supplement nursing with other food, or to 
give up nursing altogether. The question of whether to give up nursing or 
not is often a difficult one to decide. If the mother is suffering from any 
organic disease, there cannot be any doubt as to giving up nursing both for 
her own sake and that of the infant. It may happen that the breast milk 
entirely goes, and either a wet nurse must be obtained or artificial food be 
substituted ; in other cases the decision is much more difficult ; the infant does 
not appear to thrive, and the fault may be in the quality of the mother's milk. 

Much useful information may be gained by weighing the infant every 
week ; a regular gain of 5 to 6 ounces a week during the first three or four 
and 3 to 4 ounces from the third to the sixth month will indicate that the 
infant is thriving in spite of some minor troubles it may be subject to. It 
must be remembered, however, that the infant may put on fat without a cor- 
responding development in the other tissues. 

Valuable information may be obtained by an examination of the breast 
milk ; unfortunately, no mere inspection or microscopical examination is of 
any use : an analysis must be made by a competent chemist by ordinary 
methods, or approximate results may be attained by the estimation of fat by 
means of the acid butyrometer (see Appendix). Care should be exercised to 
see that the milk taken for analysis is the middle portion : that is, the infant 
should be put to the breast for five minutes or more, and then ^- 1 oz. drawn 
from the same breast by means of a breast pump. This will give a fair sample 
of the milk. The two most important considerations, as Rotch points out, 
are the amount of fat and the amount of proteids present. A low proportion 
of fat and a high proportion of proteids indicate a bad milk. 

The following analyses represent examples of human milk of different 
qualities (Rotch) : 





Normal 


Poor 


Over-rich 


Bad 


Fat 

Proteids .... 
Lactose .... 
Ash 

Total solids 

Water .... 


4 
1-2 

7 

0-2 


I-50 
2"40 
4-00 
0-09 


5-10 
3'5o 
7-50 
0-25 


o-8o 

4*50 
5'0O 
0*09 


12-13 
88-87 


7*99 
92*01 


16*35 

83-65 


10-39 

89-61 


IOO- I CO 


IOO'OO 


IOO'OO 


IOO'OO 



If the mother's milk is poor, an attempt may be made to improve it by 
prescribing a diet containing more meat and some alcohol for the mother. A 
change to the seaside is often of value. The infant may be taken at night 



44 The Hygiene and Diet of Infants and Children 

by the nurse and given one or two bottles of milk and water, so as to give 
the mother complete rest at night. 

Artificial Feeding-. 

The most convenient substitute for human milk is the milk of the cow. 
The milk of some other animals, such as the goat, ass, mare, has been used 
with more or less advantage, but cow's milk is likely to remain the all but 
universal substitute. Goat's milk has one or two practical advantages ; in 
the first place, the goat appears rarely to suffer from tuberculosis, an immunity 
which it owes to its outdoor life, while the cow is known to be very fre- 
quently affected with this disease ; and in the second place, for a family in 
the country having their own grass plot, it may be often very convenient to 
purchase a milch goat and fodder it at home. A milch goat is of course 
much cheaper than a cow, and can be kept at practically no expense. The 
chemical differences between the milk of the cow and that of the goat are 
not great, and there is no advantage except that already mentioned in sub- 
stituting goat's milk for cow's milk. 

The milk of the ass much more nearly resembles human milk than either 
the milk of the cow or goat. Unfortunately ass's milk is difficult to obtain 
in this country, and is also costly. 

Cow's iviilk. — The milk of the cow has been studied more closely than 
the milk of any other animal, on account of its great importance to the com- 
munity as an article of commerce. As a food its importance is derived fiom 
the fact that it supplies in due proportion proteids, carbo-hydrates, hydro- 
carbons, salts and water, while it contains no waste products, and, moreover, 
it is digested with comparative ease. It requires when fresh and pure no 
preparation to render it fit for consumption. 

The richness of milk is influenced in various ways — the materials with 
which the cows are fed, the length of time during which they have been in 
milk, and also by the breed. The milk supplied at our doors, it is needless 
to say, varies with the honesty of the purveyor and the cleanliness observed 
in its collection and transit. 

A superstitious belief in the superior virtues of the milk of ' one cow ; is 
still common among the public, and it is often looked upon as a most 
important matter to secure this. As a matter of fact, a good average milkis 
more likely to be obtained from mixing the milk of a number of cows than 
in taking it from one, for it is well known that the first portion of milk 
obtained from the udder is poor in fat, while the last portions are rich, the 
amount of fat varying from 2 to 8 per cent. If the first part of the milk 
taken is reserved for an infant, it is tolerably certain to get a poor milk. 
Whenever a cow is specially reserved to supply milk for an infant, care 
should be taken to see that it is sound and healthy. It should be tested 
with tuberculin by a competent veterinary surgeon. 

What is of far more importance than the question of ' one cow ' is the 
question as to the health of the cows, and how they are fed, and the care 
taken to prevent the contamination of the milk with organic matters. In 
the vicinity of our large towns it is no uncommon thing to see cows out at 
pasture in fields watered by brooks contaminated with sewage, of which they 
freely drink ; moreover, they are extremely likely to lie down in the sewage 



Cow's Milk 



45 



water, and their udders, and consequently the milker's hands, become 
befouled with sewage. In the winter time the cows are frequently fed 
largely on turnips and brewer's grains, instead of hay, maize, or other dry 
fodder : possibly also their sheds are infrequently cleaned out and only 
sparingly supplied with straw, so that the animals lie in faeces, and their 
udders may be seen caked with dried excrement. It is no uncommon thing 
to find a greenish-looking sediment in milk from second-rate dairies, due to 
contamination of faecal matters. 1 The storage of milk is an exceedingly 
important matter ; it is readily contaminated when kept in cellars or 
kitchens pervaded with sewer gas or the emanations of decomposing animal 
substances. The temperature at which it is kept is also important, as 
it far more quickly turns sour and decomposes when kept in a warm place 
than in a cool place. This is recognised by many milk purveyors, who 
take measures to cool the milk directly it is received from the cow by 
means of iced water. The day's supply of milk for the household or for the 
children should never be kept in the nursery or kitchen, but should be 
covered and kept in cool, well-ventilated cellars, or out of doors in the shade. 
According to Soxhlet fresh milk turns sour and curdles at the following 
temperatures and times : 

At 32 C. (90 F.) in 19 hours At 17^° C. (63-5° F.) in 63 hours 2 
At 25 C. (77 F.) in 20 hours At 10° C. (40 F.) in 208 hours 
At o° C. (32 F.) in 3 weeks. 

Freeman has shown by experiment the effect of temperature on the growth 
of bacteria in milk. Samples of the same milk were kept at different tempera- 
tures for twenty-four hours, and the number of bacteria estimated in a fixed 
amount of each specimen. The one kept at 45 F. had 445 • that at 50 F. 
1,362 ; that at 55 F. 67,170 ; while that at 68° F. had the enormous number 
of 134,340. 

We give here three different analyses of cow's milk : (I) a good average 
specimen according to Leeds ; (II) a pure milk according to Langlois ; 
(III) an average specimen as supplied by the milkmen of Paris (Langlois) : 





I. 


11. 


in. 


Specific gravity. 

Vol. of cream .... 


10297 


10317 
10 


io33 

77 


Fat 

1 Lactose 

Proteids ..... 
Ash 

1 Total solids .... 


375 

4-42 

376 

•68 


4 
5 

3'4 
•6 


3'34 
4-92 

3'4 
•57 


12-61 


13-0 12-23 



The Pat of milk consists principally of margarine and oleine ; it is 
present in milk as minute globules, which on standing rise to the surface in 

1 The bacillus coli communis is constantly found in ordinary milk, in consequence of 
faecal contaminations. See Brit. Med. Journal, August 31, 1895, p. 544. 

2 Temperature of ordinary kitchen. 



46 The Hygiene and Diet of Infants and Children 

the form of cream. A microscopical examination of a drop of milk display-, 
these minute globules of fat, and also colostric corpuscles and fatty 
epithelial cells if the animal has recently calved. According to some the 
fatty globules are surrounded by an albuminous envelope ; others believe 
milk to be really an emulsion, in which the fatty particles are held in 
suspension by the albumen and caseinogen in the milk. The fat can be 
extracted by shaking with ether, after the addition of a drop or two of a 
solution of caustic potash. If milk be long heated at ioo° C. or at a higher 
temperature, the emulsion is in part interfered with, and globules of butter 
oil will rise to the top if the milk is warmed ; a microscopical examination 
of such milk shows the fatty globules to have in part run together. 

The Lactose or XVTilk Sugar is the member of the carbo-hydrate group 
present in milk, and is destined to be converted into glucose, and in this 
state enters the blood of the portal vein. It is readily converted into lactic 
acid in the stomach and intestines. It is uncertain if lactic acid is present 
in normal digestion in the stomach, but in some forms of dyspepsia 
excessive quantities are formed, so that some infants who are suffering from 
chronic dyspepsia have a strong 'sour milk' odour. Possibly this rancid 
smell may be due in part to butyric acid. Lactic acid may be decomposed 
into alcohol and carbonic acid, and also into butyric acid and carbonic acid. 
The latter two processes probably only take place in abnormal digestion. 

The Proteids of milk are two in number — caseinogen and lactalbumen 
(Halliburton). In cow's milk the former is present in much larger quantities 
than the latter, the reverse holding good in woman's and ass's milk. 
Caseinogen is precipitated by acetic acid or by saturating with a neutral salt 
such as sulphate of magnesia ; lactalbumen is coagulated on boiling. 
Lactalbumen closely resembles serum albumen, but it coagulates at a some- 
what higher temperature, JJ° C. (Halliburton). It only slowly coagulates at 
this temperature, and even at a higher temperature some time is required to 
fully coagulate it. If rennet be added to cow's milk the caseinogen is 
decomposed into casein or curd of milk, which is precipitated in dense flakes, 
and a second proteid, the ' whey proteid ' which remains in solution. The 
presence of lime salts is necessary for this change to take place (Hammarsten). 
' Whey proteid' is not precipitated by heat. 

The curd of cow's milk forms a dense heavy lumpy precipitate in the 
stomach, differing very markedly from the soft flocculent precipitate from 
woman's milk. It is attacked with difficulty by the gastric juice, and a large 
proportion of it passes into the intestines practically unchanged. 

The Salts of milk consist of potash, lime, and soda in combination with 
phosphoric acid and chlorine. 

Woman's Milk. — The following figures, according to Leeds, represent 
the principal differences between cow's and woman's milk : 

Sound dairy milk Average woman's milk 

Reaction . . . acid alkaline 



Specific gravity 

Fat 

Lactose. 

Proteids 

Ash 

Bacteria 



1029 1031 

375 4-13 
4-42 7 

376 2 
•68 -2 

numerous absent 



Woman's Milk 



47 



We have taken the analyses of Professor Leeds of woman's milk as being 
the average of a large number of specimens, but the variations in different 
samples is very considerable. The analyses given by different authorities 
also differ considerably, as the following table will show. 

Woma?is Milk 





Solids 


Proteids 


Fat 


Lactose 


Salts 


Pfeiffer . 
Hoffmann 
Leeds 
Luff . 
Adriance . 


1 1 778 
12-340 
13-268 
1 1 -490 
12 


1-944 
1-030 
1-995 

2-350 
1-2 

Colostru 


3-I07 
4-070 

4-I3I 
2-4IO 

3-4 
m 


6-303 
7-030 
6-936 
6-390 

6-7 


•192 
•2IO 
•20I 
•340 
•20 


Pfeiffer . 


157 


9756 


2-954 


2-942 


•408 



The principal points to be noted are the following : (1) the excess of 
proteids in cow's milk, and the excess of curd (caseinogen) over lactalbumen 
as compared with woman's milk. According to Hirt, the amount of curd in 
cow's milk is 3 per cent, (lactalbumen -75 per cent.), in woman's milk it is 
only -63 per cent, (lactalbumen 1*5 per cent.), so that the amount of curd is 
nearly five times as great in the former as in the latter. (2) Smaller quantity 
of lactose in cow's milk. (3) The fat is about the same. (4) The ash is 
greater in cow's milk. (5) By the time the cow's milk reaches the consumer 
it is slightly acid and contains numerous bacteria, while woman's milk is 
supplied direct to the infant, and is alkaline and sterile. 

In substituting cow's milk for human milk, we necessarily endeavour to 
imitate the latter as much as possible. The great difficulty to be overcome 
is the large quantity and solidity of the curd which is thrown down in cow's 
milk when the latter comes in contact with the curdling ferment of the 
infant's stomach. Woman's milk curdles in soft flakes, which hardly offer 
any resistance when pressed between the finger and thumb, while the curd 
of cow's milk, especially if the curdling has been rapid, consists of firm 
cheesy lumps. The digestive juices of the infant's stomach and intestines 
are unable to dissolve these lumps, and, if not vomited, they partially 
decompose under the influence of the bacteria they contain, gases and 
ptomaines are formed, and much discomfort and perhaps diarrhoea or 
convulsions take place before the decomposing curd is passed in the stools. 
Any one who has had an opportunity of carefully watching the effects of 
cow's milk when taken by an infant a few days old, and noted the effect if 
the milk of a wet nurse is substituted for cow's milk, will see at once the 
difference in the quality of the stools, and the immediate cessation of the 
discomfort and indigestion which the infant is certain to have suffered when 
taking the cow's milk. The difficulty with regard to the curd can partly be 
got over by diluting and peptonising or adding malt extract, but no method 
has been discovered by which cow's milk can be rendered as digestible and 



4 8 



The Hygiene and Diet of Infants and Children 



nutritive as woman's milk. The curd thrown down from condensed milk, 
or milk which has been desiccated, appears to digest more readily and with 
less discomfort than the curd of fresh cow's milk. 

Modified IVTilk. Humanised iviilk. Cream Mixtures. — The readiest 

way to prepare an infant's food from cow's milk is to dilute with water and 
add sugar. It is plain, however, that while the resulting mixture if suffi- 
ciently diluted may be suited to the infant's digestion as far as the proteids 
are concerned, it will certainly be deficient in fat, and will not be a good 
copy of human milk. On the other hand, if only a small proportion of 
water is added, the mixture will contain a too high proportion of the proteids. 
This is seen in the table. 





Proteids 


Fat 


Sugar 


Human milk .... 


1-2 


3-4 


6-7 


Cow's milk .... 
Cow's milk 2 1 
Water 1 1 


375 
2-5 


375 
2-5 


4 

27 


Cow's milk 1 , 
Water 1 I ' 


1-37 


1-87 


2 


Cow's milk 1 | 
Water 2 f ' 


1-25 


1-25 


1 '3 



What must be aimed at is a mixture containing the various constituents 
in the proportion of an average example of human milk. 

It must, however, be remembered that it is clearly an advantage to the 
physician not only to provide the infant with a good imitation of human 
milk, but also to be able to vary the proportion of the constituents to suit 
the idiosyncrasies of the patient as well as the abnormal conditions of 
digestion produced by disease. In order to provide these advantages, milk 
laboratories have been established in various cities of the States, and other 
cities will doubtless follow. The pioneer work in this direction has been 
done by Dr. T. M. Rotch of Boston, U.S.A., and the first milk laboratory 
was established there under his direction. There must necessarily be a 
farm in connection with the laboratory, where healthy milch cows are kept 
under the most strict sanitary conditions, the most rigid care being taken to 
prevent the entrance of bacteria into the milk, and to insure a milk of good 
quality. Then by means of a 16 per cent, cream obtained by the 
separator, diluted with separated milk and a solution of milk sugar, any 
prescription sent to the laboratory can be made up and supplied to the 
patient. It is certain, however, that milk laboratories will for the present 
at least be out of the reach of the majority of practitioners, and the expense 
will stand in the way in many cases. The food of the infant will for long 
to come have to be prepared at home. Many attempts have been made by 
physicians, Biedert, Meigs, Frankland, to prepare mixtures of cream and 
milk sugar, which should be good copies of human milk. The difficulty 
has always been to obtain a cream of definite and constant strength. The 
cream of the shops varies much in strength, and moreover is often by no 
means fresh, and frequently contains boric acid or other preservative. 




15 oz- 



-J 

Fig. 9. 



Modified Milk — Humaiiised Milk — Cream Mixtures 49 

The plan we have followed for some years has been to prepare humanised 
milk by obtaining a weak cream by the gravity method, and adding to it a 
solution of sugar of milk. The details are as follows : stand 30 oz. of 
good fresh milk of average quality, as soon as it arrives at the house, in a 
glass bottle such as is supplied with Hawksley's steriliser (see fig. 9). A 
stopper of clean non-absorbent cotton wool is placed in the neck of the 
bottle ; it is allowed to stand without being disturbed for 
five hours in an ice chest or in as cool a place as possible. 
By the end of this time a certain amount of cream will 
have risen to the top. Then carefully, and without dis- 
turbing the bottle, syphon off the lower half, that is, 
15 oz., and replace this by an equal quantity of a 7 per 
cent, solution of sugar of milk (1 oz. of sugar of milk in 
15 oz. of water). The bottle is then placed in the steriliser 
and the mixture kept at a temperature of 160° F. for half 
an hour. It is then cooled as quickly as possible in run- 
ning or ice water and kept in a cool place. When the 
infant has to be fed, as much as is required is placed in 
the feeding bottle and warmed up to ioo° F. Such a 
mixture will contain about 3 to 3*5 fat, i*8 proteid, and 
6 milk sugar. 

This mixture is too strong for a delicate or very young infant, and a 
weaker mixture may be made as follows : let the milk stand as before, then 
syphon off 20 oz. and replace by the same amount of solution of sugar of 
milk (1 oz. in 20 oz.). In all cases it is as well to render the mixture 
alkaline by the addition of a few grains of bicarbonate of soda or a few drops 
of a saccharated solution of lime. We must bear in mind that the ordinary 
household milk is usually richer in winter, when the cows are stall-fed, than 
in spring, when they are out to pasture. The five hours' standing may be 
increased or shortened according to the richness of the milk. The amount 
of fat in the mixture can be readily estimated by means of the acid centri- 
fuge machine (see Appendix). 

The best way to start the syphon is to fill it with water, nip the end of 
the rubber tube so as to prevent the water from running out, carefully place 
the short leg of the syphon in the bottle so that it touches the bottom, 
release the end of the rubber tube, and the milk will flow out. 

Another method consists in allowing the milk to stand, creaming it 
with a spoon and making a mixture of cream, fresh milk, and sugar water. 
If the creaming operations are carried out with care a number of modifica- 
tions can be made (Holt, Westcott). A cream containing 12 percent, of fat 
is the most convenient for use. This can be obtained with a fair amount of 
accuracy by allowing a quart of milk of average richness to stand in a glass 
jar, surrounded by iced water, for six hours. 

At the end of this time carefully remove by skimming the cream which 
has arisen (about six ounces). By diluting this 12 per cent, cream with 
different quantities of sugar water, mixtures of varying strength will be 
obtained, the fat being throughout as compared with the proteids in a 
proportion of 3 to 1. 



50 The Hygiene and Diet of Infants and Children 

Formula obtai?ied by Diluting 12 per cent. Cream (Holt) 



Cream 


Sugar solution 


Fat 


Proteids 


Sugar 


(1)1 part 

(2) I „ 

(3)i „ 
(4) 1 „ 
(5)i „ 


5 parts = 
4 „ = 
3 „ = 

A „ = 

2 „ = 


Per cent. 

2 

2'5 

3 
3'5 

4 


Per cent. 

•6 
•8 
1 

VI 

i'3 


Per cent 

6 
6 
6 
6 
6 



In (1) and (2) the sugar solution is made by dissolving 1 oz. in 16^ oz. 
of water, and in (3) (4) (5) by dissolving 1 oz. in 14 oz. of water. 

The following table shows the amount of 12 per cent, cream, whole 
milk, and sugar of milk required for a mixture of 40 oz. (Westcott) : 



Cream 


Milk 


Milk Sugar 


Fat 


Proteids 


Sugar 


oz. 


oz. 


oz. 


Per cent. 


Per cent. 


Per cent. 


23 


13 


175 = 


2 


i-5 


6 


4-8 


io*6 


5? 


2-5 


i'5 


6 


73 


8-i 


„ 


3 


i-5 


6 


9-8 


5-6 


55 = 


3*5 


i'5 


6 


12-3 


3-i 


55 


4 


i-5 


6 



Thus if a mixture was required to contain 3 per cent, fat, 1*5 per cent 
proteid, 6 per cent, sugar, the directions would be given thus, in round 
figures : 

Cream* (12 per cent.) . 7 oz. Lime water . . . 2 oz. 

Whole milk . . . 8 oz. Sugar of milk . . if oz. 

Add water to make 40 oz. 

Whey. — Whey is an extremely useful food for a newly born or weakly 
infant. It is also often of great service as a substitute for richer foods during 
a period of indigestion. It may be often usefully employed as a diluent 
for cow's milk. It is best prepared by warming 30 oz. of milk in a glass 
bottle (see fig. 9) or saucepan to a temperature of 104 F., adding a teaspoon- 
ful or two of Benger's essence of rennet ; allowing to stand for a few minutes 
till coagulation has taken place, then stirring and agitating the contents of the 
bottle, so as to break up the curd and liberate some of the fat, then straining 
through muslin or a fine sieve ; 30 oz. of milk will yield about 23 oz. of whey. 
Whey so prepared contains about — fat 1*5 to 2 per cent., proteids -8 to -9 
lactose 475, salts -6. (F. Baden Benger.) The whey should be sterilised, 
and it will probably require straining again, as a slight separation of proteid 
takes place. In some cases of weak digestion it may be wise to dilute the 
whey with barley water. On the other hand, if it is found that whey agrees 
with an infant and it is thriving, milk may be added to the whey after 
sterilisation, and some milk sugar also added. A weak humanised milk 
may be made by mixing 10 oz. of milk with 20 oz. of whey, and adding 



Whey— Diluted Milk— Barley Water, &c. 5 1 

h oz. of milk sugar. To make a stronger humanised milk use an 8 per cent, 
cream instead of ordinary milk for the above mixture. 

Dilated Milk. — Undoubtedly the readiest way to prepare an infant's food 
is to dilute milk with water and lime water, and add sugar. That food so 
prepared is inferior to the food in which cream forms the basis is evident, 
yet it cannot be denied that very many children are brought up on diluted 
cow's milk and appear to thrive on it. Many such children pass much curd 
in their stools without being the worse for it. The poorer classes cannot 
get fresh cream, or indeed any cream at all, and have from necessity to 
prepare their infants' food from milk. As we should naturally suppose, it is 
the newly born infants who are most intolerant of cow's milk, and great care 
is required in adapting the strength of the milk to the infant's condition. It 
is necessary at first to dilute the cow's milk with two-thirds sugar water, 1 one- 
twentieth part consisting of added lime water, so as to secure that the food 
should be faintly alkaline. We should, however, much prefer to give a newly 
born baby whey or diluted peptonised milk if it is necessary to feed it 
artificially. After the first three or four weeks, if the infant's digestion 
appears good, half milk and half sugar water 2 may be given (one-twentieth 
part being lime water). From three months of age to six months, one- 
third part of sugar water should be added. 

Barley Water, Oatmeal Water, &c. — For many years past it has been 
the practice to use certain thin gelatinous fluids, such as barley water, oat- 
meal water, arrowroot water, or fluids containing maltose and dextrin, to 
dilute milk with for infant feeding. All these fluids, except perhaps the last 
named, contain small quantities of starch. Now it is certain that the powers 
of young infants for converting starch into sugar are feeble, and if these 
fluids are used care should be taken in their preparation to avoid any quan- 
tity of starch being present. The saliva of infants three or four months old 
has undoubted powers of starch transformation, and apparently the pancreatic 
and incestinal juices have also, so that by the time this age is reached we 
have nothing to fear from thin starchy fluids. It has been claimed for these 
gelatinous fluids that when used to dilute milk they play a useful part in 
preventing the curd from running together into lumps during the time that 
coagulation is taking place. It is certainly difficult to demonstrate this in a 
test tube, but it is probable that any colloidal or gelatinous fluid interferes 
with the rapid diffusion of the curdling ferment through the fluid, and conse- 
quently the curdling takes place slowly, and there is in consequence less 
tendency to the formation of lumps of curd. Neither starch nor maltose is 
present in the natural food of infants, yet experience teaches that the addition 
of a thin malted food or barley or oatmeal water has a considerable nutritive 
value, and we entertain no doubt on this point. For infants below six 
months of age, we dilute milk more or less in order to reduce the amount 
of curd present ; in doing so we render the food poorer in hydrocarbons than 
mother's milk. This diluted milk is rendered more nutritive by the addition 
of malted starch, and this is, in some instances at least, more readily assimi- 
lated than milk diluted with water only. 

1 Dissolve 1 oz. of milk sugar in 20 oz. of water. 

2 Dissolve 1 oz. of milk sugar in 15 oz. of water. 



52 The Hygiene and Diet of Infants and Children 

Peptonised Milk. — The predigestion of the curd, or rather the caseino- 
gen of cow's milk, is undoubtedly a useful resort in the artificial feeding of 
infants. It can be easily demonstrated that milk partially peptonised less 
readily curdles on the addition of rennet or acid, and that the curd thrown 
down is softer than that thrown down from fresh cow's milk. Clinical 
experience also testifies to its value, especially in infants with irritable 
stomachs or gastric catarrh. It does not, however, always agree witli 
infants ; speaking generally, it is of more use in gastric than in intestinal 
disturbances. It is not wise to continue its use for many months together : 
the infant should gradually become used to milk which has not been 
predigested. If it is the sole food for many months, especially after the 
sixth or seventh month of life, scurvy is very apt to arise. The best way to 
prepare this form of food is to utilise the cream mixture already referred 
to, and also the sterilising apparatus. A reliable peptonising powder con- 
taining pancreatine and soda may be added to the mixture when nicely 
warm (no F.), and the temperature raised during the next ten minutes or 
quarter of an hour to 160 F., or it may be carried to the boiling point. 
Peptonising for ten minutes or quarter of an hour does not much alter the 
flavour of the milk, but this time is not long enough to do more than digest 
a part of the curd. If the process is continued for half an hour to an hour, 
the curd is much more completely digested, but a bitter taste is developed. 
In quite young infants this bitter milk appears to agree very well under some 
conditions, but many infants will not take it. Peptonised milk food may be 
made from one of the well-known foods prepared by Benger & Co. or 
other reliable firms. 

Sterilisation. — Where milk can be obtained absolutely fresh and uncon- 
taminated from undoubtedly healthy cows, and is consumed at once, steri- 
lising processes are of course unnecessary, but only infants resident in the 
country, where cows are kept on the premises, can have these advantages. 
Cow's milk, as it is received by householders in towns, is usually many hours 
old before it is received, and it may be kept, or at least some portions of 
it, for twenty-four hours longer before the infant takes it. During this time 
the bacteria which it has received by means of various contaminations 
multiply enormously, especially in hot weather. Milk which is acid and 
4 just on the turn ' is, it is needless to say, quite unfit for infants' food. Many 
of the bacteria found in stale milk are probably harmless, or at any rate not 
actively mischievous ; others which may be present, especially the ' peptonis- 
ing bacteria,' are unquestionably deleterious, inasmuch as they form during 
their growth various animal poisons of the ptomaine type, which give rise 
when taken to acute diarrhoea or gastro-enteritis. 

Various pathogenic bacteria may be present in milk, either derived from 
a diseased cow, or from sewage or other contamination entering the milk. 
Tubercle bacilli may be derived from cows suffering from tuberculosis of the 
udder, and there can be no doubt that diphtheria, scarlet fever, typhoid fever, 
and foot and mouth disease may be spread through contaminated milk. 
Fortunately all these bacteria are destroyed at a temperature of boiling 
water ; indeed, there is good evidence that they cannot withstand a tem- 
perature of 75° C. if continued for half an hour. Of the saprophytic bacteria 
there are many varieties. There are the lactic acid group, and with these 



Sterilisation — Condensed Milk 53 

are the butyric acid producers. Others, which are much more important; 
are those which do not act on the lactose, but if present in sufficient numbers 
peptonise the proteids, forming peptones and albumoses. Milk containing 
the latter, if it is at all stale, given to mice or guinea pigs produces diarrhoea, 
while pure cultures quickly produce diarrhoea and death. 

Sterilising for household purposes rests on a somewhat different footing 
from sterilising in large establishments where the milk has to keep for many 
months. The milk sterilised in the household has only to be kept for twenty- 
four hours or thereabouts, and therefore so high or continuous a temperature 
is not required. The success of the sterilising process largely depends upon 
getting the milk fresh and clean, and consequently containing few bacteria 
and no spores. It is impossible in a household to sterilise stale milk. 
Stale milk is certain to contain many spores, and the spores of some of the 
saprophytic bacteria such as those which attack casein require a tempera- 
ture of 100-105 C. or more to destroy them. If the milk can be procured 
fresh and clean and is intended to be consumed within a day or two, a tempera- 
ture of jo° or 75 C, is quite high enough to expose the milk to. This tempera- 
ture does not affect the taste or coagulate the lactalbumen. If milk has 
to be kept a longer time or is not very fresh, it is better to expose it to a 
temperature of ioo° C. for half an hour. Milk which is long heated at ioo° C. 
or especially a higher temperature suffers certain changes, the chief of 
which is connected with the coagulation of the albumen and the partial 
destruction of the fat emulsion. In such milks some of the fat floats in the 
form of large globules of butter on the top of the milk when it is warmed. A 
brown colour is developed on account of the partial destruction of the lactose. 
Milk long heated suffers coagulation less perfectly than raw milk ; this is 
due to the precipitation of some of the calcium salts. There can be no 
doubt that the formation of the butter oil is a disadvantage ; how far the less 
perfect coagulation of the curd is an advantage it is not easy to say. 

Various forms of apparatus have been devised for sterilisation in the 
household, the best known being on the Soxhlet type. This form can be 
used for heating to 100 C. or to the lower temperature of 75 C. (167 F.). 
Hawksley has also devised a steriliser with a thermometer, which is con- 
venient and reliable. Aymard's steriliser is also convenient for the purpose. 
Freeman's is much used in America. 

Condensed Milk. — Condensed milk has long been a favourite substitute 
for mother's milk among the lower classes, and its use is by no means con- 
fined to the lower orders, though it has had but few defenders among 
medical men. The fact that some brands contain a large proportion of added 
cane sugar has condemned it in the eyes of most medical writers, and many 
serious allegations have been made against it. It has been accused of pro- 
ducing eczema, diarrhoea, constipation, rickets, scurvy, and it has been 
alleged that while children who have been brought up on it are fat and 
plump, they readily succumb when attacked with acute disease. On the 
other hand, it is sterile when taken from a freshly opened tin, and does not 
readily undergo fermentative changes in the stomach. It will often be 
retained when so-called fresh milk is vomited or gives rise to flatulence and 
colic. We believe it may often be substituted for fresh milk with advantage 
as a temporary resort, care being taken to select a reliable brand which 



54 The Hygiene and Diet of Infants and Children 

contains a full percentage of fat. The best varieties are those which have 
been preserved without the addition of cane sugar, and to which cream has 
been added. We should not advise condensed or any form of preserved 
milk for months together on account of the risk of scurvy. Care should be 
taken when a tin is opened to make sure that the milk is in good condition, 
as occasionally a tin containing partially decomposed milk may be met 
with. 

In using condensed milk accurate directions must be given as to the 
strength to be employed and also as to the manner of measuring it. A 
graduated measure should be employed and the milk poured into it. For an 
infant of three months old it may be diluted i in 8 by weight, or what is nearly 
equivalent to this, i in 10 by measure. It should rarely be used stronger 
than this, but it maybe necessary to dilute to i in 15 or 20 for very young 
infants, and in special cases. 

Diluted to 1 in 8 by weight, we shall have the following composition 
(Leeds) : 

Sweetened Diluted 

condensed milk i in 8 by weight 

Fat .... i2-io 1-51 



Lactose 
Cane sugar 
Proteids . 
Ash . 

Total solids 



16*62 2-06 

22-26 2-78 

16*07 2 ' QI 

2-61 -32 

69-66. 8-68 



It is important to use a good brand of condensed milk, inasmuch as 
the cheaper forms are deficient in fat. The ■ Milkmaid ' brand contains 
nearly 12 per cent, of fat, while some other brands have less than 2 percent. 

Some good brands of condensed milk may be obtained without added 
sugar. The following is an analysis of the ' Viking ' brand ; it will be seen 
that it corresponds with a good milk which has been concentrated by driving 
off two-thirds of the water. A measured ounce of this milk weighs 480 grs., 
that is one-tenth more than an ounce of water. It can be diluted for use 1 in 
4 or 6 by measure. 



Fat . 
Lactose 


Unsweetened 
condensed milk 

. 9-9 
• I3-3 


Diluted 
1 in 6 by weight 

1-65 

2*2 


Proteids . 


. . 8-9 




1 "5 


Ash . 


. 1-9 
. 34-0 




•16 


Solids 


5*51 



It will be seen by examining the second columns that each of these foods 
is deficient in fat, while the latter is deficient in carbo-hydrates, but this can 
be remedied by adding sugar. It is well to bear in mind that in all concen- 
trated or desiccated milks the calcic phosphates are thrown down in a more 
or less insoluble form, and in preparing the food in the ordinary way are 
only in part redissolved. 

Dried Milk Foods. — The difficulties attendant on the preparation and 
storage of sterilised milk for sale have brought into the market various 



Dried Milk Foods 55 

preparations of desiccated milk. These will keep good in any climate, and 
occupy only a small bulk as compared with liquid preparations. They are 
unquestionably convenient, are sterile, and their proteids are more readily 
digestible than the proteids of much that passes as fresh milk. Messrs. 
Allen & H anbury prepare two forms of desiccated milk food. The following 
analysis is from the ' Lancet : ' 

A. and H.'s No. i food Diluted 1 in 8 by weight 

Fat .... 13-15 1-64 

Lactose and dextrin . 65*48 8*19 

Proteids . . . i4'25 178 

Salts .... 475 6 

In using this food accurate directions should be given for its preparation. 
The useful tablespoon should not be used as a measure, but a dry graduated 
measure glass. Six measured drachms (220 grs.) of No. 1 food weigh half 
an ounce, water is to be added to make up 4 oz. in all. 

The composition of No. 2 food is very similar, but with a small quantity 
of malt extract added. No. 1 is most suitable for the first three months of 
life, and No. 2 for the next three months. No. 3 food consists of a malted 
starch food and requires mixing with fresh milk. 

The chief value of these dried milk foods consists in their being useful 
substitutes for fresh milk, when the latter cannot be obtained, or when the infant 
suffers from frequent vomiting, colic, or diarrhoea. They do not readily 
ferment in the stomach, and consequently less gas is formed, as compared 
with some forms of fresh milk. At the same time it is certain that they 
cannot be perfect foods inasmuch as they are deficient in fat and also in 
lime salts. The added water does not redissolve the whole of the calcium 
salts in the food. If continued for many weeks or months, specially if the infant 
is over six months of age, both scurvy and rickets are very apt to ensue. 
Some of the worst cases of scurvy which we have seen have been in infants 
fed solely on desiccated milk foods. 

Amount of Food to be given. — The amount of food to be given to an 
infant must necessarily depend not only on its age, but also on its digestive 
powers and its development. It is evident that it is quite as important to 
carefully regulate the times of taking food and the amount to be taken, as it 
is to decide upon the nature of the food. It must of course be borne in 
mind that the amounts given below are for an infant of average weight and 
digestive powers. Neither age nor weight should be taken blindly as a guide 
to the amount of food an infant should take. For the first two or three 
weeks (weight 6 to 8 lb.), give 1 to 2 ounces of food every two hours and a 
half in the daytime ; 8 bottles being given, and 12 to 15 ounces of food being 
taken in the twenty-four hours. 

During the second month (weight 8 to 11 lb.), 3 to 4 ounces of food every 
two hours and a half ; 8 bottles being given, and 20 to 30 ounces being taken 
in the twenty-four hours. 

During the third and fourth months (weight 11 to 14 lb.), 4 to 5 ounces 
of food every three hours ; 7 bottles being given, and 30 to 35 ounces being 
taken in the twenty-four hours. 

During the fifth and sixth months (weight 14 to 16 lb.), 6 to 7 ounces of 



56 



The Hygiene and Diet of Infants and Children 



food may be given every three hours ; 6 bottles being given, and 35 to 40 
ounces being taken in the twenty-four hours. 

Feeding: Bottles.— The simplest feeding bottles are the best. It is wise- 
to avoid all those provided with india-rubber tubes, corks, and those that 
have indented letters on their surfaces. The rubber tubes soon crack and 
become rough inside, corks absorb some of the food and quickly become 
foul, while any indentations on the inner surface of the bottle make it 
difficult to scour clean with a brush. The best class of bottles are those 
with rather wide mouths (see fig. 10), or such as are supplied with Soxhlet's 
or Escherich's milk sterilisers, and are perfectly plain and fitted with large 
teats that can be turned inside out for the purpose of cleansing. The 
small teats supplied with the fancy bottles cannot be 
readily cleaned. The bottles after being used should be 
thoroughly cleaned with a brush kept for the purpose, 
and inverted so that they may drain and no dust may 
be allowed to get into them. It is important that the 
food should not be given too hot ; at a temperature of 
98 F. it is quite warm enough. 

Diet from 6 to 12 Months. — While some mothers 
are strong enough, and are sufficiently good nurses, to 
suckle their children to the end of the first year, there 
are many others who begin to flag about the 6th or 7th 
month, and in such cases it is desirable to supplement 
the breast by means of some milk food. There is no 
lack of artificial or patent foods from which to choose. 
If the infant is entirely dependent upon artificial food, 
it should take from i| to 2 pints of good cow's milk 
every twenty-four hours, between 6 months and 1 year. 
Whether this should be given undiluted must depend 
upon the digestive powers of the infant, which may be 
gauged by its power of digesting casein as determined 
by an inspection of its stools and by its growth and 
weight. Some form of starchy food may be added with 
advantage, for now the digestive powers of the infant are 
sufficiently advanced to form dextrine and maltose out 
of starch, thus forming a valuable and easily assimilated 
carbo-hydrate. Care must be taken that all starchy matters are thoroughly 
boiled, so that the starch granules become gelatinised, as raw starch is less 
easily digested. 

Barley jelly, whole meal flour, maize, oatmeal, all answer very well 
if thoroughly cooked and made sufficiently thin to pass through the teats of 
ordinary feeding bottles. 

If the digestion of starch is not proceeding well or if curd is being passed 
in the stools, malt extract or ' Bynin ' may be added to the food after it has 
been boiled, and allowed to become just cool enough to taste ; it is then set 
aside for a few minutes before giving it. Five meals in the twenty-four 
hours will, as a rule, be sufficient, some 6 to 8 oz. being taken at each 
meal. The first meal may be taken between 7 and 8 A.M. ; the second 
between 10 and 11 A.M.; the third, 1 to 2 P.M. ; the fourth, from 4 to 




Feeding Bottles $7 

5 P.M. ; and the fifth, the last thing at night. There is no harm in giving 
the infant a well-toasted crust to nibble, but thick foods should not 
be allowed, and beef tea and eggs are certainly unnecessary and best 
avoided. 

During the 7th, 8th, and 9th months, 3^ oz. to 3 oz. will be an. average 
gain, and by the end of the 9th month 20 lb. weight may be reached. 
During the last three months 2 oz. to 1^ oz. per week ; and the weight is 
usually over 22 lb. by the end of the first year. 

It must not, however, be forgotten that infants may put on fat which 
naturally adds to their weight without their being necessarily strong and 
healthy. Care must be taken to weigh them at the same time of day, so that 
there may be no mistake. 

At twelve months of age, if the child be strong and healthy, the bottle 
may be gradually left off, and food of a more solid character may be substi- 
tuted, but milk is still to be the staple food. 

Diet from Twelve Months to Eighteen Months of Age 

First meal, 7.30 A.M. Fine bread sops with milk, or oatmeal or hominy 

porridge made with milk. 
Second meal, 11 A.M. A drink of milk. 
Third meal, 1.30 P.M. Bread crumbs and gravy or a lightly boiled egg and 

bread and butter. Sago or rice pudding. 
Fourth meal, 5.30 p.m. Bread and milk. 
Fifth meal. Milk to drink. 

After eighteen months of ag-e, when healthy children have cut their first 
set of double teeth, small quantities of fish, fowl, or meat may be allowed. Of 
fish, boiled whiting, sole, or cod, carefully freed from all the bones, is readily 
taken by most children. Boiled fowl is better than butcher's meat in early 
childhood. Of the latter, underdone mutton chops, torn into shreds and 
mixed with bread crumbs or well-mashed potatoes, are the best and most 
digestible kind of butcher's meat. Rice, sago, and tapioca puddings, stewed 
apples, and preserves of various fruits, may be allowed. Children unfortu- 
nately are often strangely fastidious in their tastes, and will frequently take 
a dislike to many forms of the most digestible foods. It is always well to 
introduce as much variety as possible into their diet. 

For old«r children hominy porridge with treacle for breakfast, to be 
followed by small quantities of bacon or egg, with cocoa or weak tea, are 
as a rule well digested and are beneficial, provided that the porridge or 
bread and milk forms the piece de resistance of the repast. Soups made 
in various ways from meat and vegetables form an exceedingly wholesome 
and digestible meal. Pastry, as a rule, is bad ; boiled rice with raisins and 
stewed fruit of various kinds are much to be preferred. 

When the child is old enough to sit up to table at dinner and take meat 
cut from a joint, the greatest care should be taken to see that the meat is 
carefully cut up into small pieces before it is put into the mouth, and is 
thoroughly masticated before swallowing. So important is this, that if there 
is any doubt as to the cutting up by the nurse, it will be well to insist that all 
the meat should first be put through a mincing machine ; the gravy can 



58 The Hygiene and Diet of Infants and Children 

be afterwards added to it. Masses of half-masticated meat will not be 
digested if bolted in the usual way, and will be passed almost unchanged in 
the faeces ; and if the food is thus bolted, it is less satisfying, and leads to 
more than is required by the system being consumed. A stand must always 
be made against the common practice of giving children biscuits or ginger- 
bread at almost all hours of the day. The stomach requires rest like every 
other organ in the body, and is certain to become deranged if sweet things 
are being taken at all times. 

The Care of Immature and Weakly Infants. — Infants born before the 
full time of forty weeks require special care in nursing and feeding, and this 
is true also of delicate infants born at full time. Infants born before the 
thirtieth week and weighing under 2 $ lb. only exceptionally live more than 
a few hours. There are, however, instances on record of infants weighing 
under 2 lb. at birth being successfully reared. In one case under the care 
of Dr. A. Mumford which he brought under our notice the infant weighed 
1 lb. 14 oz. at birth, it survived, and has since done well. Villeman and 
Charpentier and others have recorded somewhat similar cases. Those born 
at the thirtieth or thirty-first week and weighing i\ to 3 lb. have a better 
chance of being reared, though the mortality among such is very high. 
Those born at the thirty-sixth week and weighing 4 to \\ lb., or at the 
thirty-eighth week weighing 4^ to 5^ lb., have a good chance of surviving, 
but require exceptional care. 

For the most part premature infants have but little subcutaneous fat, 
and feeble powers of maintaining their temperature ; they quickly lose heat 
and readily succumb if exposed to cold. They are usually of a dull-red 
colour from the asphyxiated condition of blood, their skin hangs in loose folds, 
their movements are sluggish, and the cry is feeble in consequence of the 
partial expansion of their lungs. The muscles are limp and toneless, the 
respiratory and sucking movements wanting vigour as compared with an 
infant born at term. No washing operations must be attempted, but the 
infant as soon as it is separated from the placenta must be completely 
enveloped in warm dry absorbent cotton wool. Separate pieces may be 
made to envelop the limbs, and another piece in contact with the buttocks 
to absorb the urine and faeces. It is wrapped in blankets or woollen wraps, 
placed in a padded basket or box, and kept warm with hot-water bottles. 
The cotton wool diaper can be removed when soiled, and the rest of the 
cotton wool wrapper may be renewed daily if the condition of the infant 
admits of the necessary handling and exposure. The apartment must be 
kept at a temperature of 70 F. at least ; much higher than this will render 
it very uncomfortable for the mother and attendants. It is well to have a 
cylinder of oxygen in the apartment to use for the infant in case of 
necessity. 

The feeding of premature infants is likely to be a matter of some diffi- 
culty ; the infant may be too feeble to suck, and very likely no milk may 
make its appearance in the mother's breasts. The breast milk in these cases 
is likely to be more rich in proteids than ordinary colostric milk, and conse- 
quently may disagree, giving rise to sickness and diarrhoea. It will probably 
be the best plan to draw off the mother's milk at intervals, dilute with 
warm water, and give it to the infant with a pipette with an india-rubber ball 



Care of Immature and Weakly Infants 59 

attached. Failing the mother's breast, sterilised whey may be given (1, p. 50), 
or, in case of a very weakly infant, the whey must be diluted with an equal 
quantity of water. Two to four drachms may be given hourly. If there is 
much vomiting, or if the infant is not taking its food well, the food should be 
introduced direct into its stomach by means of a rubber catheter. (See 
Gavage, Appendix.) 

The introduction of Incubators or Brooders has undoubtedly been the 
means of saving the lives of premature infants, especially in maternity 
hospitals, where the infant can be placed at once after birth in the apparatus. 
An incubator usually consists of a small chamber, which can be kept at a 
temperature of 90 F. if need be, and is well ventilated. Various forms have 
been designed for the purpose ; the one most used in this country is 
Hearson's, 1 the Couveuse Lion 2 being largely used on the Continent. It is 
needless to say that the management of a baby-incubator requires the 
attendance of intelligent and experienced nurses. 

1 235 Regent Street, London, W. 

2 26 Boulevard Poissonniere, Paris. 



6o Diseases of the Digestive System 



CHAPTER IV 

DISEASES OF THE DIGESTIVE SYSTEM 

Examination of the Mouth. — An inspection of the cavity of the mouth 
and fauces in infants and children is of great importance, and mistakes in 
diagnosis are exceedingly likely to be made if it is neglected. In newly born 
infants the mucous membrane of the mouth is comparatively dry, and con- 
tinues so for the first two or three months of life ; the secretion of saliva 
becomes gradually freer as the glands develop, and the infant begins to 
dribble, for it is some time before it learns to swallow its saliva and to keep 
its mouth shut. The lining of the infant's mouth is at first of a dull red 
colour, and flocculi of milk are often to be seen adhering to it, as the move- 
ments of the tongue and lips are imperfect, and there is but little secretion 
of fluid to cleanse the mucous membrane. All through infancy and early 
childhood the mucous membrane is exceedingly apt to become the seat of 
various lesions. The membrane is necessarily delicate, the epithelium is easily 
injured, and affords a favourable ground for the cultivation of cryptogamic 
growths and various micro-organisms ; hence the frequency with which we 
find parasitic stomatitis and various superficial ulcerations and aphthous 
patches. 

Inspection of the mouth of the newly born may reveal various abnorma- 
lities, some of minor importance, such as the small millet-seed nodules 
situated in the middle of the roof of the mouth, a shortened fraenum linguae, 
or the presence of small clear swellings (ranula) beneath the tongue. Among 
the important abnormalities may be mentioned cleft palate, or an abnormally 
high arched roof. 

All through early life there is a tendency to hypertrophy of the lymphatic 
tissues in the naso-pharynx and fauces. It must be borne in mind that the 
passage through the naso-pharynx in infants is exceedingly narrow, and the 
presence of adenoid excrescences or enlarged pharyngeal tonsil, which may 
perhaps be congenital, may seriously interfere with the infant's respira- 
tion, and in some instances seems to excite ' choking fits,' or spasm of the 
glottis. 

Dentition.- — The influence of dentition upon the health of the infant de- 
pends very much upon the child's constitution. A strong and vigorous infant 
which has been brought up at the breast will cut its teeth one after another 
without trouble, and but for the appearance of the teeth through the gums 
the friends will not be aware that dentition is in progress. On the other 
hand, if the infant is rickety, weakly, or the inheritor of neurasthenic tenden 
cies, the period of dentition will be a period of danger, and the irritation 



Dentition 61 

caused by the pressure of the tooth expanding its sockets and cutting through 
the gum is very liable to give rise to various forms of disease, the process of 
dentition acting rather as the exciting than the predisposing cause. The 
first dentition begins during the middle of the first year, and ends usually by 
the appearance of the posterior molars in the middle of the third year. In 
some, without any known cause, the first teeth make their appearance before 
this time ; indeed, it is not infrequent for infants to be born with a tooth 
already cut : such teeth, however, are imperfectly developed, and consist 
merely of a thin shell of enamel. Some by no means strong children cut 
their teeth early. In rickets dentition is delayed ; in those cases in which 
rickets makes its appearance prior to the sixth month, dentition may not 
commence during the first year, the infant being toothless at a year old. In 
other cases the infant only becomes rickety towards the end of the first year, 
when the incisors are perhaps through the gum, and then there follows a 
long delay. 

By the fifth or sixth month saliva is formed in large quantities, so that it 
is frequently dribbling from the mouth, and the infant is constantly putting 
its finger into its mouth, as if there were some sort of irritation going on 
there. A month or so later the gums may become tender, the whole mucous 
membrane congested, aphthae appear on the tongue, inside the lips, or on the 
hard palate, and the infant is feverish and cross to a degree. Perhaps now 
the edge of a tooth, usually one of the lower middle incisors, will be felt 
through the gum. Some days or even weeks will perhaps elapse before the 
edge of the tooth is actually cut. It is a singular but by no means unusual 
circumstance for a tooth to advance so as almost to stretch the mucous 
membrane of the mouth, and then become stationary for some time. 

Now while it is the almost daily experience of the practitioner that the 
process of cutting the first teeth gives rise to discomfort, he knows also that 
mothers and nurses are ever ready to attribute every childish illness to the 
teeth. Many infantile ailments are mysterious in their origin, especially 
attacks of feverishness, and in children under two years old there is always 
a tooth nearly cut, or has just been cut, or is about to be cut, to supply the 
explanation. It is this popular tendency to attribute every childish ailment 
to the teeth, which explains the large sale of ' teething powders.' The 
danger is that important errors in diet, a patch of pneumonia, or meningitis 
may be overlooked if the teeth are allowed to explain everything. While it 
is unwise to shut our eyes to the disturbance and discomfort produced by a 
stretched and swollen gum, care is needed to avoid using the explanation of 
' tooth cutting ' to cover ignorance or merely to satisfy the clamour of an 
anxious mother for a definite opinion as regards her child's illness. It is a 
good rule always to seek for an explanation elsewhere than in the teeth, if 
there is no local lesion in the gum, such as swelling, tenderness, or some 
evidence of inflammation. 

Feverishness. — When the gum is swollen and tender prior to the cutting 
of a tooth, the infant is apt to be irritable, having fits of crying without any 
apparent cause, which nothing will pacify ; at first gently rubbing the gum 
will give ease, but at a later stage this only aggravates the trouble from the 
acutely painful state of the gum. The fever is intermittent, the child being 
hot and feverish for the most part at night and unable to sleep, while towards 



62 Diseases of the Digestive System 

morning it cools down and dozes for a few hours ; the temperature may 
reach 102 or 103 , rarely more. Such attacks may often pass away without 
the tooth being cut, or may continue for some time after the edge of the 
tooth has appeared, and before the rest of the tooth has made its way 
through. 

Stomatitis. — The mucous membrane of the mouth, more especially that 
part of the gum where the tooth is about to appear, the tongue, hard palate, 
and inside of the cheeks, may be the seat of small superficial ulcers or small 
spots denuded of epithelium, their surface being of a grey or yellowish 
colour, and their edges surrounded by a zone of erythematous redness. 
These spots are evidently sore, and may be the cause of the infant refusing 
the breast, and crying whenever liquids containing salines, such as beef tea, 
are taken. 

Enlarged Glands. — Occasionally it happens in children predisposed to 
glandular enlargement that the irritation caused by these aphthous patches 
gives rise to a swelling of the glands, either the submaxillary when the lower 
jaw is affected, or the parotid or upper cervical lymphatic glands, which receive 
the lymph from the upper jaw. These swellings may quickly subside, or 
end in either acute or chronic suppuration. In the latter case successive 
teeth being cut keep up the source of irritation. 

Diarrhoea — During the hot months of late summer and autumn, the 
irritation of teething may be the exciting cause of intestinal catarrh and 
diarrhoea. In infants a transference of a lesion from one part of the body, 
more especially from one mucous membrane, to another, is exceedingly 
common ; this diarrhoea is especially common in artificially fed infants. No 
diarrhoea should be attributed to tooth cutting, unless there is some local 
lesion in the gums or mouth. 

Bronchitis. — During dentition, especially when the incisors are being cut, 
infants seem very prone to catarrh of the bronchial tubes, which may be 
complicated by catarrhal pneumonia. 

Eczema a?id Lichen. — It constantly happens that infants who suffer, or 
are liable to suffer, from eczema are much worse while a tooth is pressing 
through the gum. The eczema very frequently gets well in the intervals, 
the face and body being free, until a tooth comes near the surface, and 
there is a return of the eczema, the face and forehead flush up and papules 
appear which begin to ooze and crust. Lichen in the form of strophulus or 
urticaria is also common. 

Co?ivirisions. — It may be taken for granted that no healthy infants suffer 
from convulsions ; those who do are either rickety or the children of neurotic 
parents, and inherit a tendency to nerve disturbance. Spasmodic affections 
of various groups of muscles occasionally take place. 

Treatment. — Much controversy has arisen from time to time with regard 
to the use of the gum lancet, and the propriety of employing it in assisting 
dentition, many practitioners being in the frequent habit of using it, while 
others have not employed it for years. If the mucous membrane over the 
tooth is red, swollen and tender, and the edge of the tooth can be felt, much 
pain and discomfort will be spared the infant by its use, presuming, of 
course, it is not a ' bleeder,' nor comes of a family in which there is a history 
of haemophilia. The relief afforded is due in all probability to the local loss 



Dentition 63 

of blood ; as well as to the relief of tension in the gum. That it has been 
done often unnecessarily, and that many troubles are attributed to dentition 
that have no connection with it, is no argument against the use of the lancet 
in proper cases. The evidence is too strong to be lightly explained away, 
that fits of crying, feverishness, or even convulsions may be quickly relieved 
by freely lancing a swollen and tender gum. It, perhaps, need not be said 
that it is useless to lance the gum unless there is evidence that the cutting 
edge of the tooth is near the surface, or disappointment will certainly follow. 
In one case coming under our notice, in which an upper incisor was lanced 
in a rickety child, the tooth was not cut till exactly a year after the operation. 
The feverishness and tenderness in the mouth and sleeplessness may be 
generally relieved by mercurial purges, bromides, or simple salines (F. 1 
and 2). As much as five grains of bromide may be given if the infant is 
very restless, or two or three grains of chloral hydrate, or a mixture containing 
two and a half grains of each in a teaspoonful of syrup. Painting a tender 
and swollen gum with a saturated solution of bromide of sodium in glycerine 
and water will often relieve pain. If the gums remain spongy, or there is 
aphthous stomatitis, borax with tinct. myrrh may be used (F. 3). 

The temporary teeth differ in size and hardness in different children ; 
in weakly rickety children they are not only late in appearing, but when they 
do appear are dwarfed and consist of mere shells, quickly becoming black 
and carious, or loose and falling out of their sockets. In other children the 
enamel appears deficient, and caries occurs early. Great care should always 
be exercised in the preservation of the first set of teeth. A soft tooth brush 
should be used every night, and the mouth thoroughly cleansed with warm 
water, in order to dislodge the fragments of food which have collected 
between the teeth. If the teeth show signs of caries, it is a good plan to 
use the tooth brush after every meal, mixing a few drops of an alkaline 
mixture with the water (sp. ammon. aromat. Jj, sp. vini rect. giij). Whenever 
it is possible, carious temporary molars should be properly filled. 

The second dentition is not accompanied by the same troubles as the 
first, or at any rate to the same degree. The first molars and incisors usually 
make their appearance unobserved, and rarely occasion any inconvenience. 
The second molars may give more trouble. It sometimes happens that the 
gums get into an unhealthy state, being spongy and bleeding readily, while 
the teeth become loose and give pain during mastication. It is during this 
period that ulcerative stomatitis may be present. Gumboils may be another 
source of trouble. If it is of importance to attend to the cleansing of the 
mouth during early childhood, it is of still greater importance to do so when 
the permanent teeth are appearing, and no effort should be spared to prevent 
their premature decay. 

The structure of the permanent teeth is no doubt influenced by the 
state of the health during infancy. We have already referred to the fact 
(p. 14), that illness taking place during the first year of life may affect the 
permanent set of incisors and canines, while the bicuspids and first molars 
probably and last two molars certainly escape. Mr. Hutchinson long ago 
pointed out that congenital syphilis often gives rise to a peculiar formation 
of the incisors of the permanent set. The ' test teeth ; for syphilis are the 
upper central incisors ; the effect of this disease occurring during infancy is 



64 Diseases of the Digestive Systci/i 

to arrest their development, causing dwarfing and also a central notch at 
the cutting edge, or perhaps a ' screw-driver ' form of tooth ; the other 
incisors may share in this want of development, but only in a secondary 
degree. Mr. Hutchinson has also pointed out that stomatitis occurring 
during infancy gives rise to a pitting or erosion of the enamel. The 'test 
tooth ' for infantile stomatitis being the first molar, the incisors also may be 
affected, and they may be grooved by a ' transverse furrow crossing all the 
teeth at the same level.' In some cases the pitting of the upper surface of 
the molar produces well-marked rugosities (erosion en mamelori). Other 
deficiencies of the enamel of more or less extent have been described by 
French authors. Mr. Hutchinson believes that the stomatitis giving rise to 
this condition is often mercurial in its origin, mercury having been given in 
the form of 'teething powders' or in other ways. Mr. Moon used to speak 
of a ' mercurio-syphilitic ' tooth in which there was a want of enamel over 
a semilunar space near the cutting edge, and in consequence a breaking 
down of the enamel over this area. M. Magitot attributes erosion of the 
teeth to the effects of infantile convulsions, but it is probable the convulsions 
are coincident only. 

It is by no means always easy to explain why some children have good 
teeth with perfect enamel, while in others the enamel is deficient and the 
teeth quickly become carious. There cannot be any doubt, however, that a 
strong and vigorous infancy and early childhood with a good digestion and 
careful feeding must favourably influence the development of the teeth ; 
while infants who suffer from dyspepsia and are badly fed will suffer later 
on from bad teeth. No doubt apparent exceptions may occur. 

Diseases of the Mouth 

Catarrhal Stomatitis. — Catarrhal inflammation of the mouth may be 
primary, but it is more often secondary, accompanying dentition, dyspepsia, 
pneumonia, and other diseases. Stomatitis is especially apt to make its ap- 
pearance during the first year of life, though it is common during the whole 
of childhood. Infants who are thus suffering, having begun to take the breast, 
suddenly let it go and cry, and are apt to stuff their fingers in their mouths ; 
they are feverish and irritable, the saliva is increased in quantity, and the 
mouth feels hot if the finger be inserted ; the salivary glands, especially the 
sublingual, are swollen and tender. On examination of the oral cavity, 
patches of intense redness are to be seen on the mucous membrane inside 
the cheek, on the gums, or hard palate, the tongue is generally bright red 
and clean, or the surface is covered with a thick creamy fur, the edges and tip 
being clean and red. This form of stomatitis is often called stomatitis 
erythematosa. Very frequently at the seat of these erythematous patches, 
an exudation of yellowish or greyish secretion takes place, or there is a 
breach of surface where the epithelium is abraded, and small shallow 
ulcers are formed. These yellowish patches or ulcers are surrounded by 
a zone of redness Such patches are usually termed Aphthae, and when 
present the term 'aphthous stomatitis' is often applied. Older children are 
subject to these attacks, and it is often seen to affect a whole household at 
the same time, the adults by no means always escaping. It is uncertain if 



Catarrhal Stomatitis 65 

it is contagious, but it is certainly epidemic ; it is sometimes associated 
with tonsillitis. There may be feverishness, the temperature rising to 103 , 
accompanied by the appearance of vesicles on the mucous membrane of the 
lips, tongue, and soft palate ; the vesicles soon disappear, being followed by 
patches of yellow exudation, or a shallow ulcer may remain. The spots 
remain sore for several days. The term of Herpetic Stomatitis is 
sometimes applied to this form. Similar attacks have been described as 
occurring both in infants and children from drinking the unboiled milk of 
cows suffering from ' foot and mouth ' disease ; and in any case where these 
affections occur in a widespread epidemic it is well to make careful in- 
quiry into this as a possible cause. There are probably several distinct 
diseases resulting from specific micro-organisms included under the term 
' aphthous stomatitis.' Fraenkel has found pus cocci, such as Staph, ftyog. 
citreus and albus, as well as 'gas-forming bacilli,' in stomatitis. During 
attacks of tonsillitis, scarlet fever, measles, &c, aphthae often make their 
appearence on the tongue and inside the lips, while the corners of the mouth 
become excoriated. 

Sometimes patches of greyish-white or yellowish membrane form on the 
edges or sides of the tongue ; this form has been called Membranous 
Stomatitis. It has nothing to do with diphtheria, but streptococci have 
been found in the fibrinous exudation. 

In infants aphthous patches, two in number, situated on the hard palate, 
one on each side of the median raphe, near the junction of the hard and soft 
palate, are often seen ; these are round surperficial ulcers \-^ in. in diameter, 
their base being of a yellowish colour and surrounded by erythema. They 
have been described as Bednar's aphthae, or plaques pterygoidiennes by 
Parrot. They are produced by the pressure of the back of the tongue against 
the hard palate in sucking. They have nothing to do with syphilis. 

The treatment must depend upon the cause, whether the stomatitis 
depends upon dentition, gastro-intestinal catarrh, or other pathological con- 
dition. In most cases a mild purge will be useful to expel any indigestible 
food present in the alimentary canal, to be followed by some small doses of 
rhubarb and soda. It is doubtful if chlorate of potash is of any use in this 
form. 

Locally the spots may be touched with a solution of permanganate of 
potash (5 grs. to the oz.) or boric acid (15 grs. to the oz.). If the spots are 
slow in healing, they may be touched with lapis divinus. This latter consists 
of equal parts of sulphate of copper, alum, and saltpetre fused together. The 
diet should consist of milk and barley water made more dilute than usual, 
and for older children milk and sops. Beef tea and saline fluids are generally 
objected to on account of causing smarting in the mouth. (F. 5, F. 6.) 

Parasitic Stomatitis. Thrush. — This form of stomatitis differs essen- 
tially from the forms already described, as it is due to the presence and growth 
in the epithelium of the mouth of a species of cryptogam. It is especially 
common in newly born infants and in those of a few months old, who are 
suffering from some form of wasting disease, and in whom the mucous 
membrane of the mouth is in an unhealthy condition. But it is also found in 
infants during the last half of the first year, less commonly during the second 
and later years. It appears as small white distinctly raised points or scattered 

F 



66 



Diseases of the Digestive System 



patches on the soft palate, mucous membrane of the check, lips, and tongue. 
While its chief seat is the mouth, it has been found in the larynx, ccsophagus, 
stomach, caecum, and in one or two instances in the lungs. If touched with 
a small paint-brush, the patch is found to adhere firmly to the mucous 
membrane and cannot be detached as can milk flocculi, for which it may 
readily be mistaken ; if forcibly detached there is left a red surface denuded 
of epithelium. The mucous membrane of the mouth is often red and 
unhealthy around the patches, in other cases it is quite normal. In mild 
cases these white patches are small and few in number ; in severe cases they 
become confluent and large, and the surface of the tongue and cheeks is 
covered with them. Infants so affected are mostly weak and ill, and often 
suffer from diarrhoea or gastric catarrh with wasting. It occurs in older 
children in the last days of tuberculosis, tubercular meningitis, typhoid, and 
pneumonia. 

If a piece of the white patch be detached and examined microscopically, 
it will be found to consist of epithelial cells, bacteria, yeast fungi, and the 

thread-like filaments of various 
mould fungi. The identity of the 
fungus which gives rise to the 
disease is a matter of uncertainty, 
the difficulty of identifying it being 
largely due to the presence of 
various organisms in the white 
patches. It has been identified 
as the Oidium tactis, the mould 
fungus which is present in sour 
milk ; the cultivations of Grawitz 
led him to believe it to be identical 
with the yeast fungus or wine fer- 
ment {Saccharomyces mycoderma). 
Rees, who further investigated it, 
believes it to be a yeast fungus, 
though not identical with the above ; he gave it the name of Saccha- 
romyces albicans. The micro-organism of thrush is most probably, as 
Fraenkel states, a link between the yeast fungi {Saccharomycetes) and the 
mould or thread fungi (Hypomycetes). It can be cultivated in syrup, gelatine, 
or potatoes and bread paste ; under certain conditions of nutrition it appears 
to resemble the yeast fungi, as on the surface of the gelatine ; while at the 
bottom of the test-tube cultures it appears more like the thread-like forms of 
the mould fungi. It is aerobic, and does not liquefy gelatine. 

The fungus usually appears in the form of filaments made up of cells 
jointed together 3-4 /z broad and 50-60 \x long ; these branch in various 
directions ; oval cells bud out from the joint between the elongated cells ; 
spores are present in these roundish cells. (See fig. 11.) 

Treatment. — It is of much importance that great care should be taken to 
cleanse the mouth after the infant has taken the bottle, especially in a weakly 
infant of low vitality, weak alkaline solutions, just tinged with Candy's Fluid, 
being useful for this purpose. This can be done with a large paint-brush or 
soft wet rag, and on the first symptoms of thrush the borax lotion (F. 3) or 




11. — Fungus of thrush ( 
{After Crookshank.) 



Parasitic Stomatitis — Thrush 6j 

similar solution should be used. As a stronger application to the parasitic 
patches a solution of sulphate of copper (2 grs. to the oz.) or carbolic acid 
(2 grs. to the oz.) is very effectual when applied with a paint-brush. The 
success of the treatment depends not only on the destruction of the fungus 
but also on an improvement in the child's general health. (F. 5, F. 6.) 

Haemorrhagic Stomatitis occurs in infantile scurvy. (See p. 192.) 

Ulcerative Stomatitis. — This form only occurs in children who have cut 
teeth, and is most common after the molars have been cut. It occurs in chil- 
dren both with healthy and also with carious teeth. The children who suffer 
from it in the severe form are unhealthy, and are either recovering from some 
infectious disease, or have been badly fed, or have been exposed to unhealthy 
surroundings ; it is also common in tuberculous children. The early symp- 
toms are feverishness, salivation, and smarting when food or drink is taken. 
When the attack is developed, an examination of the mouth will show that 
the gums are much swollen and tender, and a purulent secretion is present 
along their free edges. The breath is foul, and some bleeding takes place 
from the swollen gums. The ulceration may extend to the mucous membrane 
of the cheek, especially that part contiguous to the lower molars. Here a 
deep ulcer with a yellow base may often be seen, and the fissure between the 
cheek and gums may also be involved. The side of the tongue is affected in 
some cases. Bernheim has recently described two micro-organisms, a 
bacillus and spirochete, which he believes to be specific. Ulcerative 
stomatitis appears at times to be epidemic and contagious. 

Necrosis of the jaw is apt to follow in some of the more severe cases of 
ulcerative stomatitis ; instead of the process ceasing, as it. usually does, the 
mischief spreads and a chronic osteomyelitis of the jaw is set up, much 
intensely foetid discharge comes away, the child's health suffers, the cheeks 
become puffy and flabby, the ulceration of the gums spreads, and after a 
while it is found that a large piece of jaw, carrying perhaps two or three teeth, 
is loose ; if this is taken away, in some instances the process stops ; often, 
however, any new bone that may have formed becomes infiltrated with the 
foul discharges, and the mischief spreads along the jaw, piece after piece is 
taken away, until at last the entire jaw may have to be removed. We have 
removed the whole bone from condyle to condyle for this condition. Many 
surgeons believe that the disease begins as a periostitis and not as an ulcera- 
tion of the gums, and that alveolar abscess is the starting-point ; this maybe 
so sometimes, though certainly not always. 1 

The child's health materially suffers from the discharge and foul state of 
the mouth. In one instance, after removal of the jaw, the child was sent home 
convalescent, but died suddenly, apparently from falling back of the tongue. 
Restoration of the jaw is very imperfect in these cases, for the new bone 
necroses as fast as it forms. The process closely resembles phosphorus 
necrosis, but it is not due to that poison. 

Treatme?tt. — After every meal the mouth should be well rinsed with 
warm water or Condy's Fluid, and the gums and teeth cleaned with a bit of 
absorbent wool or soft rag, not' sponge, so that the same bit may never be 
used again ; the gums should then be mopped over with the glycerine of 

1 Dr. Angel Money has reported a case coming on after typhoid and affecting the upper 
jaw. The lower jaw is the one most commonly attacked. 



68 Diseases of the Digestive System 

borax i parts to tincture oi myrrh i part. Of internal remedies, by far the 
most efficient is chlorate of potash, given in three to fi\e grain doses three 

tunes a day or more. In the large majority of cases this if given early will 
quickly cine the disease twenty or twenty-five grains in the twenty-four hours 
is a sate amount to give, but should not be continued for more than a week. 
It may be follow ed by an iron tonic. The diet should consist of fluids and sops, 
beef tea and other nourishing liquids being given freely, especially in those 
cases where the disease occurs in the poorly nourished and underfed. This 
treatment will usually suffice to arrest the disease ; but once the bone becomes 
seriously involved, in some cases nothing seems to have any effect. Strong 
nitric acid, carbolic acid, &c, seem to have little power, and the purulent 
infiltration only ceases when the whole bone has been destroyed. These plans 
should, however, be carefully tried, chloroform being of course given, and 
subsequently there should be very frequent cleansing of the mouth with equal 
parts of rectified spirit and water. As soon as the disease has ceased to 
spread, any loss of bone or teeth should be supplied by a plate with artificial 
teeth, to prevent falling in of the lips and the prematurely senile appearance 
thus produced. Even where the alveolus alone is destroyed, since no new- 
formation of bone occurs the permanent teeth are often loosened and fall 
out. (F. 4, F.3, F. 5.) 

Alveolar Abscess is, as might be expected, a very common result of the 
neglect or mismanagement of carious teeth. After an attack of toothache 
the pain may completely subside, and swelling of the face over either the upper 
or lower jaw rapidly come on. This, of course, means that the inflammatory 
process — hitherto limited to the alveolus, and hence giving rise to great 
pain, because there is great tension on a large nerve — has extended to 
the soft parts covering the bone by escape of the pus from the alveolus. 
The pain is greatly lessened, or ceases altogether. The condition is thought 
of little importance, and no steps are taken to obtain advice, as there is 
no longer pain, and a swelled face is looked upon as the natural and proper 
ending of a toothache. No doubt most of these cases get perfectly well 
at least for a time, for the abscess bursts either by the side of the tooth 
or more often through the alveolus and gum, and discharges itself into 
the mouth. Finally, the abscess closes up, and all remains quiet till some 
failure of health or some irritation rouses the carious tooth to another 
outbreak. In not a few cases, however, neglect to remove the "source of 
irritation — i.e. the carious tooth — gives rise to one or other of the following 
troubles. Often a sinus remains inside the mouth leading through the 
alveolus to the fang of the dead tooth, and a constant discharge of a small 
quantity of foul pus takes place within the mouth. Such a condition cannot 
but be prejudicial to a child's health. The breath is foul, and the foul fluid 
is swallowed, poisoning alike the lungs and stomach, and often a child is 
kept ailing for months, for want of extraction of a carious tooth. In other 
cases, the abscess tracks to the surface and is allowed to burst there, giving 
rise often to a lifelong disfigurement, in the shape of a depressed scar over 
upper or lower jaw. Or, again, a chain of enlarged lymphatic glands or a 
glandular abscess owes its origin to neglect of a carious tooth or alveolar 
abscess. Necrosis of the jaw often results from similar neglect. Occasionally, 
too, we see cases of antral abscess in children as a result of extension of 



Alveolar Abscess 



6 9 



mischief from a tooth, though it is perhaps less common in children than we 
might expect. There is a most unreasonable objection both on the part of 
parents and of some dentists to extraction of teeth, even if they are ex- 
tensively carious, and even if they are only temporary teeth. It is difficult 
to believe that the retention of a dead or carious temporary tooth can do any- 
thing but harm to the jaw and the underlying permanent teeth. It is perhaps 
still more difficult to understand the principle on which objection is made 
to the removal of a tooth while there is an abscess present, yet it often hap- 
pens that delay is urged till the abscess is well. In all cases a carious 
temporary tooth should be removed at the least sign of inflammation about 
it or if it causes foul breath. In all cases a tooth that has given rise to an 
alveolar abscess should be removed, and if its extraction does not empty 
the abscess a free opening should be made inside the mouth, and the abscess 
cavity and whole mouth frequently 
washed out with some antiseptic lotion 
till all is well again. On no account 
should an abscess be allowed to track 
towards the surface of the face, nor 
should any tooth be allowed to remain 
in the jaw with a sinus leading down to 
its fang. If antral abscess is met with 
or necrosis of the jaw, they must be 
dealt with by the ordinary methods, 
bearing in mind the softness and thin- 
ness of children's bones. We had in 
1895 under our care a child with exten- 
sive tubercular disease of both antra, 
which probably arose from the irritation 
of carious teeth. 

Gangrenous Stomatitis. Cancrum 
Oris. — Cancrum oris occurs almost in- 
variably in squalid, half-starved children 
after one of the exanthemata ; some- 
times, however, it seems to have no 
such predisposing cause. The disease 
begins as an inflamed spot on the inner surface of the cheek or upon the 
gum, the mischief rapidly spreads, both in depth and area, and the whole 
thickness of the cheek and gum becomes involved. On the outer surface the 
cheek is swollen, shining, stiff, and pale, or sometimes dark red, its vessels 
are thrombosed, and soon a black spot appears in the centre of the pale 
waxy area ; the cheek is perforated, the black spot becomes a definite slough 
which partially separates. Then the edges of the gap become black and the 
sloughing spreads, preceded by a zone in which the skin is pale and 
cedematous. In severe cases the whole side of the face is rapidly destroyed, 
the gums slough away, the jaw necroses, and the teeth drop out. There is 
intense fcetor of the discharge and breath ; which poisons the child, frequently 
causing pneumonia and death before the process is complete. Sir S. Wilks 
considers that when the sloughing attacks the gum first it may be only a n 
aggravated form of the ulceration met with in a late condition of scarlet 




Fig. 12. — Deformity resulting after recovery 
from cancrum oris ; subsequently remedied 
by a plastic operation. Dr. Wilkinson's case. 



yo Diseases of the Digestive System 

fever ; this is seen usually in the lower jaw, while in true cancrum oris the 
upper jaw is attai ked. 1 

In a fair number of instances the process is arrested and the sloughing 
ceases, the parts < Kan up and heal rapidly, leaving, of i ourse a more or 
less severe deformity. In fatal cases death is due to exhaustion or septic 
pneumonia. The amount of pain and distress suffered is variable, sometimes 
but little of either exists. 

Treatment. -The treatment of cancrum oris consists in the free local 
application of the actual cautery, or, better, of pure nitric acid. The child 
should be put under chloroform and the parts carefully dried with lint ; 
sticks dipped in strong nitric acid should then be rubbed well into the 
edges of the sloughing parts and over the surface of the gums, after cutting 
away any loose sloughs and removing sequestra. Care must, of course, be 
taken not to allow the acid to run over the sound skin. Several applica- 
tions of the acid should be made, the parts being dried after each. After- 
wards, a little iodoform should be powdered on and the surface smeared 
well with carbolic oil. E. C. Kingsford has had good results from the appli- 
cation of perchloride of mercury, but it has not proved universally successful. -' 
No less important than the local treatment is the free administration of 
stimulants and abundant nourishment. As much wine or brandy as the 
child will take (about 3-4 ounces of brandy in twenty-four hours for a child 
of five years), carbonate of ammonia and bark, eggs beaten up with milk, 
strong soup and meat extracts should be given. In these cases, as in 
phlegmonous erysipelas, patients seem to be able to take almost an un- 
limited amount and to thrive on it. Opium should be given, but with 
caution, as it is not always well borne. If the child recovers, the deformity 
is often remediable to a considerable extent by a plastic operation. Perhaps 
the most troublesome after condition is closure of the mouth by adhesions ; 
an attempt to prevent this should be made during healing by the use of 
screw gags or mouth-openers, and later, by division of the scar tissue ; in 
some cases even section of the jaw and the establishment of a false joint 
may be required. It must be confessed, however, that the treatment of 
this cicatricial contraction is far from satisfactory, and often no permanent 
good result is obtained. 

Some cases of cervical cellulitis (so-called angina Ludovici) closely re- 
semble cancrum oris in their results. (See p. 245.) 

Acute Tonsillitis. It is hardly possible to exaggerate the importance 
of a thorough examination of the throat of a feverish child, especially when 
the cause of its illness is not obvious. A child, more particularly a young one, 
does not, like an adult, volunteer the information that its throat is sore and 
painful during the act of swallowing, and will even deny that it is sore when 
it is actually suffering from severe tonsillitis. Without a careful examina- 
tion it is quite possible to overlook not only tonsillitis but scarlet fever or 
diphtheria, especially if there is some chest complication present to throw 
the observer off his guard ; or he may come to the conclusion that a case of 
submaxillary ' mumps,' or croupous pneumonia with physical signs delayed, 

1 An excellent description and figure are given in Mr. Cooper Forster's book on the 
Surgical Diseases of Children. 

2 Lancet, Sept. 1891. 



A cu te Tonsillitis 



7i 



is a case of scarlet fever. Any one who has had any experience of a fever 
hospital will be able to call to mind many cases where errors have been 
made through neglecting to examine the tonsils or from want of knowledge 
of their appearance in health and disease. 

Children are very liable to tonsillitis in its broadest sense, and this is in 
harmony with the fact that the lymphatic system during childhood is ex- 
tremely active, and especially prone to inflammation. The use which the 
tonsils fulfil is uncertain, but, whatever their exact function, it is certain 
that they belong to the lymphatic system, and they have been justly com- 
pared to Peyer's patches, inasmuch as they resemble them in structure, con- 
sisting of congeries of lymph follicles or so-called 'solitary glands.' They 
have a large blood supply, and their lymph sinuses freely communicate 
with the lymphatics of the mouth and pharynx, and also with the deep 




Fig. 13. — Vertical section of human tonsil (x 20), Landois and Stirling. 
1, crypt ; 2, epithelium infiltrated with leucocytes below and on the left, 
but free on the right ; 3, adenoid tissue with sections /-,/,/, of lymph folli- 
cles ; 4, fibrous sheath ; 5, section of mucous gland duct ; 6, blood-vessel. 



cervical glands situated behind the angle of the jaw. Their surfaces are 
covered with deep clefts or crypts which serve to increase the surface of the 
mucous membrane covering them ; these are apt to become filled with thick 
yellowish secretion, and are then seen as yellow points scattered over the 
surface. One of the functions of the tonsils is probably the formation of 
leucocytes, or white-blood corpuscles, which are shed into the salivary secre- 
tion, and the cheesy secretion formed during inflammation consists princi- 
pally of these bodies. Tonsillitis occurs under the influence of many different 
conditions during childhood, and possibly the proneness of the tonsils to 
inflame is, in part at any rate, the result of their position at the entrance of 
the fauces, where the various forms of aerial poisons, bacilli or other germs, 
would, when inhaled, be especially likely to lodge. Many of the zymotic 
diseases are accompanied, or, what is a very significant fact, are preceded, 



j 2 Diseases of the Digestive System 

by tonsillitis. Thus the tonsils arc the Mat of inflammation in scarlet fever 
and diphtheria. Typhoid fever and influenza sometimes commence with sore 

throat, measles and rothcln are mostly attended with some congestion or 
catarrhal inflammation about the fauces. The tonsils are apt to become in- 
flamed as the result of cold, as from a wetting or exposure to a draught or 
keen east wind, and possibly also from some gastric disturbance. There can 
be little doubt also that tonsillitis is at times due to inhaling sewer gas or 
unwholesome smells. It also appears sometimes to precede or accompany 
an attack of acute rheumatism, or peri-endocarditis. 

The record of tonsillar complication is not complete without reference 
to the epidemics of sore throats which are apt to occur in schools, hospitals, 
and other public institutions, or wherever many children are brought 
together. Some of these epidemics have appeared to be modified scarlet 
fever, diphtheria, or influenza, as proved by their belonging to a scarlatinal 
or diphtheritic epidemic which was coexistent in the neighbourhood or pre- 
ceded or followed the epidemic of sore throats. But in other cases it has 
been clearly shown that there is an epidemic or infectious form of sore throat 
which closely resembles both scarlet fever and diphtheria, but which, while 
similar in many respects, is actually distinct, as shown by its not protecting 
from either of the above diseases. 1 In some of these attacks of tonsillitis, 
streptococci, pneumo-cocci, colon-bacilli, and other organisms have been 
found. Some cases of epidemic sore throat have apparently been traced to 
the consumption of the milk of cows suffering from ' foot and mouth ; disease. 
Whenever sore throats occur in a household or school, the possibility that 
they are the result of the scarlatinal or diphtheritic poison should always be 
kept in view, while at the same time the milk supply and the sanitary 
condition of the establishment should be carefully investigated. 

To whatever cause the tonsillitis is due, whether sporadic or epidemic, 
the symptoms are mostly the same. The attack usually begins suddenly, 
though it is often preceded for a few hours by a feeling of soreness in swallow- 
ing. Unlike scarlet fever, it is usually unattended by vomiting ; the evening 
temperature runs up to 103 or more, the tonsils are swollen and red, there 
is much secretion of mucus, and in a few hours yellow points make their 
appearance upon the tonsils, the result of secretion retained in the crypts. 
(See fig. 14.) The tongue is furred, but does not become of a ' strawberry ' 
appearance as in scarlet fever. In some cases, instead of the yellow points 
seen on the tonsils there is a yellowish exudation formed by the coalescence 
of the yellow spots on the inner surfaces of the tonsils ; this does not adhere, 
as a rule, with any degree of firmness, and may be removed with a brush. 
The inflammatory lesion remains for the most part tonsillar, and shows but 
little tendency to spread and involve the nasal mucous membrane or the middle 
ear, and, while the glands at the angle of the jaw may become enlarged, 
they are not hard or surrounded by cellulitis. There is no true ulceration of 
the tonsils or sloughing of the palate. The temperature remains remittent 
for a few days, gradually returning to normal. 

Such is the clinical history of an attack of acute catarrhal tonsillitis, but 
it must be remembered that many such attacks are exceedingly mild, and 
are accompanied by but little pyrexia, and may perhaps come and go 
1 Vide Tonsillitis in Adolescents, by C. Haig-Brown, M.D. 



A cu te To j i sit y litis 7 3 

without much complaint being made about them. Acute tonsillitis from any 
cause is apt to leave the tonsils enlarged, and the mucous membrane 
covering them in a condition of chronic catarrh. Repeated attacks in 
children liable to glandular swellings, accompanied as they are by catarrh 
of the naso-pharynx in many cases, give rise to various troubles which will 
be described later on. 

Diagnosis. — The most important question to consider, when called to 
see a case of tonsillitis, is whether scarlet fever and diphtheria may be 
excluded with certainty ; as, if they can, it is tolerably certain that the case is 
not one which will give rise to any anxiety either on account of the patient 
himself or his friends. Unfortunately, however, it is not often possible to 
express an opinion without misgivings ; that which appears to be a simple 
tonsillitis may be scarlatinal or diphtheritic in origin. It need hardly be said 



Fig. 14. — Acute Tonsillitis. «, child aged three years ; b, child aged four years. These 
two cases belonged to an epidemic of sore throats ; scarlet fever was not certainly 
excluded, but in no case was there a rash. 



that the child suffering from tonsillitis should be stripped and a careful 
examination made of the surface of the body by a good light in order to 
detect a rash, and the faintest rash would necessarily arouse suspicion. In 
the absence of a rash a certain diagnosis is often impossible, but glandular 
enlargement, discharge from the nose, much redness of the fauces with 
yellow exudation on the tonsils, true ulceration of the tonsils or soft palate 
or otitis, if present, would make the diagnosis of scarlet fever a probable one. 
wShould desquamation follow, if it is certain there has been no rash, it is of no 
diagnostic importance. If nephritis occur in the third week, it points to the 
scarlatinal nature of the attack as beyond doubt. A strawberry tongue is 
rarely present in the absence of a rash. The difficulty of diagnosis between 
mild diphtheria and tonsillitis accompanied by greyish exudation is hardly 
less than that between tonsillitis and scarlet fever in the absence of a rash. 



74 Diseases of the Digestive System 

Albuminuria, nasal discharge, glandular enlargement and cellulitis, and the 
presence of Loeffler's bacillus in the exudation, all point to diphtheria ; if 

paralysis follow, the diagnosis of diphtheria is certain. In all doubtful cases 
a swab should be taken of the secretion and submitted for bacterial exami- 
nation. (Sec DlPHTHER] \. 

Treatment. — Every attack of tonsillitis during childhood should be 
treated not only with respect but with suspicion, and the case should at 
once be isolated as far as it is possible to do so. It should constantly be 
before the mind of the practitioner that the case may be one of abortive 
scarlet fever or diphtheria, and that the next case to which he is called in the 
same household may be a genuine attack of one of the above zymotic diseases. 
It is always wise, when called to such cases, to give a guarded diagnosis 
and prognosis until the case has been under observation for a few days. 
The patient is to be confined to his room or to his bed, according to the 
severity of the attack, and his diet should consist of milk, beef tea, and sops. 
If there is much pain in swallowing, hot fomentations medicated with bella- 
donna or opium may be applied externally and renewed at frequent intervals. 
The tonsils should be painted with a solution of boro-glyceride in water 
(1-12), or iodine gr. ij, glycerine 5j> an d water 5J ; black currant jelly or 
lozenges are also useful. Salines, such as the citrates or chlorates of the 
alkalies, combined with aconite or salicylate of soda, if there is much fever, 
may be given during the febrile stage ; acids and cinchona during con- 
valescence. (F. 7, F. 8, F. 9, F. 10.) 

Chronic Tonsillitis. — So-called chronic tonsillitis, or tonsillar hyper- 
trophy, is a very important child's disease, though by no means limited 
to childhood. The affection consists in an actual overgrowth of the tonsillar 
adenoid tissue, so that the tonsils become greatly enlarged and project as 
rounded or irregular masses in various directions. Most commonly they 
grow inwards towards the middle line, and may reach such a size as to meet 
and be flattened by mutual pressure ; they may then almost completely block 
the orifice of the pharynx. In other instances they enlarge vertically and 
become large oval masses, projecting far down into the pharynx and upwards 
and backwards towards the posterior nares. In other cases again they 
protrude outwards, separating the layers of the soft palate and forming a 
bulging mass on the roof of the mouth. Sometimes the surface is almost 
smooth, marked only by the orifices of the tonsillar crypts, and sometimes it 
is quite rugged and irregular. 

The causes of chronic enlargement of the tonsils are probably the various 
irritations, mechanical and other, to which they are exposed, just as in the 
case of masses of lymph gland tissue elsewhere. 

The overgrowth is often accompanied by recurrent attacks of acute in- 
flammation, in other cases there is no pain or acute distress at any time. 
The secretion of the mucous glands may be retained, and thick pellets of 
inspissated matter be shut up in the crypts. Occasionally, on examining 
the region of the tonsil, instead of the usual appearance, a large yellow mass 
will be seen blocking up the whole of that side of the pharynx : it is soft and 
fluctuating, and on incision gives exit to a large quantity of thick debris of 
mucus, pus, cholesterine, &c. This condition we have sometimes thought 
to be a congenital mucoid cyst. It is rather alarming at first sight, and looks 



Chronic Tonsillitis 75 

like a large abscess on the point of bursting. The symptoms are those of 
tonsillar hypertrophy with more or less dysphagia. 

The ordinary enlarged tonsil is usually pale, and in old cases hard and 
sometimes almost cretaceous. The enlargement may be found at any age 
from birth (being sometimes congenital) to puberty, or more rarely later ; it 
gives rise to a definite series of symptoms, all or most of which are usually 
present together. There is a vacuous, heavy look, from obstruction to 
breathing and consequent imperfect aeration of the blood, also imperfect 
development, and often stunting of growth ; the mouth is kept open, the 
breathing is stertorous and in sleep snoring. These children usually sleep 
heavily but restlessly, often starting in their sleep ; incontinence of urine is 
sometimes present, a result, no doubt, of the supply of imperfectly aerated 
blood to the nervous centres. There is usually chronic nasal and often 
aural catarrh, from the extension of irritation from the tonsils to the neigh- 
bouring mucous surfaces. The speech is nasal and indistinct, the chest is 
often ill-developed, pigeon-breasted, or, as pointed out by Lambron, has 
the diaphragmatic constriction (M. Mackenzie). Recurrent acute tonsil- 
litis is generally complained of, but there is seldom constant dysphagia ; 
there is an increase of the pharyngeal mucus due to catarrh, and the breath 
is often foul. The actual dwarfing and stunting from this condition is some- 
times very marked. We have seen a difference of several months' growth in 
twins, one of whom had enlarged tonsils, the lost ground being rapidly 
regained after removal of the glands. 

It is in our experience true that enlargement of the tonsils is nearly always 
accompanied by the presence of the closely allied adenoid vegetation in the 
naso-pharynx, to be mentioned presently. Occasionally, however, either 
may exist without the other. The lingual tonsil appears to be much less 
often affected, or at any rate it very seldom gives rise to any symptoms. 
We think it is more common to find adenoid growths without enlargement 
of the tonsils than hypertrophic tonsils without adenoids. 

Treatment. — Chronic tonsillar hypertrophy, when once well established, 
is little affected by mere local applications or constitutional treatment ; it is 
only during an attack of acute inflammation that good can be done by such 
means. In the early stages of the affection astringents, such as glycerine of 
tannin, and tonics sometimes succeed. The only efficient mode of treat- 
ment is by removal ; caustics and the actual cautery are inferior methods of 
obtaining" the same result. 

For that form of enlargement in which the tonsils project inwards, or in- 
wards and downwards, nothing is so efficient, simple, or easy as removal 
with the guillotine. 1 Chloroform should be given if the child will not allow 
removal otherwise ; there is no objection to it except that it makes the 
operation somewhat more troublesome. 

As much tonsil as can readily be removed should be taken away, but it is 
not necessary to remove the whole gland ; the part left behind usually soon 
shrinks. Both tonsils, if enlarged, should, if possible, be removed at one 
sitting. 

1 Fahnestock's is the one that we prefer, though it is a somewhat delicate instrument 
and liable to get out of order ; those usually sold are too large and clumsy for con- 
venient use. 



7 6 Diseases of the Digestive System 

The guillotine cannot be satisfactorily used unless the tonsils project con- 
siderably towards the middle line ; in many cases, however, its use may be 
made easier by pressing the tonsil inwards with the finger applied to the 
neck just in front of and below the angle of the jaw.' Where the overgrowth 
is outwards and the guillotine cannot grasp the tonsil, the vulsellum and 
guarded blunt-pointed bistoury must be used, care being taken to keep the 
edge of the knife turned somewhat inwards. In some few cases even this is 
impracticable, and it is only in these rare instances that puncture with the 
Paquelin cautery should be employed ; the cautery may be thrust through 
the anterior pillar of the fauces, or directly into the gland between the pillars 
at one or two points ; shrinking is said to usually follow. Potassa fusa is 
sometimes used, but is dangerous and tedious ; scraping away the tonsils 
with a sharp spoon is the best plan if the gland is very friable and soft. 

Removal of enlarged tonsils while acutely inflamed is usually condemned. 
We have, however, done it with great relief to the patient ; it is, of course, 
very painful for a few minutes. 

After removal some swelling often follows, and may last for a week or so, 
but then subsides. After free removal the enlargement rarely recurs. We 
have, however, seen two or three instances where a re-growth, larger even 
than the original one, has appeared after a lapse of some months. We 
should be inclined to look with suspicion upon such cases as possibly indi- 
cating a tendency to lymphomatous growth elsewhere. 

We have unintentionally enucleated a tonsil with the guillotine on 
several occasions, the whole gland coming away entire instead of being cut 
through ; the result was, of course, satisfactory. It has recently been pro- 
posed to revive this old method of enucleation, but we think in the majority 
of cases it will not be found practicable. 

After the operation iced milk only should be allowed for the first day, 
and milk and soft food for the next day or two ; after this the ordinary diet 
may be gradually resumed. Painting the tonsils with glycerine of tannin 
after the operation is perhaps useful. 

We have never seen bleeding follow the operation to any serious extent ; 
when it does occur it usually arises from injury to the pillars of the fauces, 
which are sometimes stretched over the tonsil so tightly as to be indistinct. 
A little ice to suck is all that is needed in most cases ; should there be any 
severe bleeding, pressure or the application of the cautery might be re- 
quired. Injury to the carotid is, of course, out of the question. 

The argument against the excision of tonsils, that the overgrowth subsides 
as the child grows up, is altogether invalid in any severe case, for the mis- 
chief to the general development, and often to the hearing power, is done 
before the tonsils subside. There is no foundation for the idea that any 
wasting of the testes occurs from removal of the tonsils ; it is much more likely 
that a lack of development should be due to the tonsillar enlargement than 
the reverse. The operation is an altogether harmless and beneficial one. 

Tonsillar Calculus is a very rare condition, due to collection of secretion 
or inflammatory material and subsequent calcareous degeneration ; the tonsil 

1 The tonsil cannot be felt externally, but a lymphatic gland lies just on its outer side, 
and when enlarged is often mistaken for the tonsil (Treves). 



Tonsillar Calculus 77 

is enlarged, hard, and often painful, the calculus can be felt with a probe, and 
should be turned out of its cavity. 

For the connection of tonsillitis with adenitis, the reader is referred to the 
chapter on Diseases of the Lymphatic Glands. 

Enlarged Uvula. — The uvula is sometimes acutely inflamed as part of 
a pharyngitis or is chronically enlarged ; in the latter case it may require to 
be snipped off. We have also met with cases of papilloma of the uvula. 

KTasal Adenoid Growths. — It often happens that a child is brought with 
all the symptoms of tonsillar hypertrophy — chronic nasal catarrh, pinched 
nose, nasal obstruction, snoring, nasal voice, deafness, stupidity, &c. {vide 
Chronic Tonsillitis), and yet the tonsils are little if at all enlarged, or if 
they are their removal does not cure the affection. In such cases there is pro- 
bably overgrowth of the post-nasal adenoid tissue, the '•pharyngeal tonsil] or 
t Luschkds tonsil] so called. This condition, which was first described by 
Meyer, is very common in childhood and is often overlooked ; it is, how- 
ever, readily found out and treated if its symptoms are remembered. 

A finger passed back into the pharynx and turned up behind the soft palate 
to the posterior nares will feel warty, sessile, or pedunculated masses about 
the upper surface of the pharynx and round the posterior nares, often almost 
completely blocking the apertures. An excellent opportunity of seeing these 
growths is afforded by cases of cleft palate, in which they are nearly always 
well marked. 

These excrescences bleed readily, but are not tender to the touch. In 
such cases, the vegetations should be scraped away with a Gottstein's curette, 
supplemented if necessary by the use of a Volkmann's spoon passed through 
the nose and guided by a finger in the pharynx. Meyer's ring scraper and 
Lowenburg's forceps are sometimes useful, the latter especially if the growths 
are very tough. It is far better in these cases to give chloroform and do the 
operation thoroughly than waste time and trouble by incomplete scrapings 
with the finger-nail or applications of the cautery or other such means. If 
done thoroughly by the method recommended, it is vary rarely necessary to 
repeat the operation, though occasionally growths so small as to escape 
removal subsequently enlarge and require treatment. It is best to operate 
with the child's head thrown well back over the end of the table, so that no 
blood trickles into the air passages. This operation is one that should be 
strongly insisted upon ; it removes a source of many troubles and much 
weak health. 

The affection is an exceedingly common one, and may be met with at all 
ages. We have seen it in quite the first few months of life, and we believe 
it is sometimes congenital. No treatment except mechanical removal is 
to be recommended, though the application of caustics may in some cases 
be effectual. 

Pharyngitis Gangraenosa. — We have met with two cases of pharyngitis 
in which extensive ulceration occurred, and which did not appear to be due to 
diphtheria, scarlet fever, or other zymotic disease. One of these cases was 
a hitherto healthy boy aged nine years ; there was little fever, but much indura- 
tion and cellulitis at the angle of the jaws. When seen by one of us, it was 
impossible even under chloroform to get a good view of the fauces ; there were 
one or two smart haemorrhages from the mouth presumably from ulceration. 



78 Diseases of the Digestive System 

1 [e was apparently recovering when a sudden haemorrhage occurred, evidently 
from the throat, and proved fatal almost immediately ; no post-mortetn was 
obtained. In the second case there were no haemorrhages, but a deep 
ulceration of the tonsils and pharynx ; the disease much resembled in its 
onset and course gangrenous stomatitis, and proved fatal. 

Post-pharyngiai Abscess.— Abscess in the prevertebral fascia is 
usually the result cither of caries of the cervical spine (see SPINAL DISEASE) 
or of suppuration of the lymphatic glands in this region from irritation about 
the pharynx or posterior nares. The symptoms are dysphagia and dyspnoea, 
with pain and dribbling of saliva or mucus ; a peculiar nasal or palatal 
resonance in the cry is described by Politzer.' On examination, a soft 
fluctuant swelling will be felt, and the posterior wall of the pharynx will be 
seen to project unduly, and possibly the yellowish colour of the pus may be 
seen through the mucous membrane. When the abscess is due to simple 
mucous irritation it should be opened through the mouth with a guarded 
knife, the child being turned on its face as soon as the incision is made, to 
allow the pus to flow out readily. We have seen post-pharyngeal inflamma- 
tion, without any visible pointing, give rise to so much dyspnoea as to render 
tracheotomy necessary. Occasionally a large mucous cyst, such as that 
described as occurring in the tonsil, is found on the posterior wall of 
the pharynx ; free incision is all that is required for these conditions. In 
other instances suppuration tracks round the outer side of the pharynx 
from the tonsil or soft palate or from suppurating cervical glands or other 
neighbouring parts. Where there is external evidence of abscess it is better 
to make the opening in the neck, so that the wound may be rendered 
aseptic, as in abscess from spinal disease. Other causes of post-pharyngeal 
abscess are injuries and pharyngitis ; it may also occur in the course of scarlet 
fever or be the result of a breaking-down gumma. Many cases are recorded 
by Bokai as idiopathic ; it is not improbable that some of these were 
glandular. Wiel gives otitis as a cause. Convulsions, facial paralysis, great 
swelling of the neck, and spasm of the sterno-mastoid may sometimes occur 
(M. Mackenzie). The disease has been mistaken for many different affec- 
tions, probably most often for croup. Examination of the throat by the eye 
and finger will always clear up a doubt in the later stages, though, as already 
pointed out, the diagnosis may be very obscure at first. 

We have met with these abscesses in quite young infants as well as in 
older children. In a case that we saw a finger passed into the abscess cavity 
could find its way between the vertebrae and the pharynx upwards nearly to 
the base of the skull, and downwards almost to the root of the neck. The 
abscess was probably the result of suppuration in a retro-pharyngeal lymphatic 
gland, and caused both dysphagia and dyspnoea. 

Retro-cesophageal abscess sometimes occurs, and may give rise to dyspnoea 
necessitating tracheotomy, rarely to dysphagia ; it may be due to spinal 
caries or extension of suppuration from other parts. 2 It is not so common in 
children as the retro-pharyngeal abscess. When it occurs there is swelling 
on both sides of the neck, dryness of the throat, tenderness and pain on 
movement, with fever and alteration of the voice. The abscess may burst 
1 Jahrbuch f. Kinderheilk . B. xxi, H. i, 2. 
- Ripley, Archiv. of Pediatrics, Feb. 1884. 



P ost-pJiaryngeal Abscess 79 

into the oesophagus or burrow round the neck. We have recently met with 
three cases of abscess bursting into the oesophagus : in two caries of the spine, 
and in the other tuberculous gland disease was the cause of the abscess. 
According to Barthez and Rilliet, a form of dry coryza, with even coma or 
convulsions, may occur, and the onset may be sudden. After the abscess 
has burst, ' traction diverticula,' or stricture of the gullet, may result. The 
prognosis is bad. Fomentations and feeding by enemata or an oesophageal 
tube should be the early treatment, with incision at the posterior border of 
the sterno-mastoid as soon as there is distinct evidence of suppuration. 

Stricture of CEsopbag-us. — Apart from congenital malformations, 
oesophageal obstruction in children is due either to paralysis, or to cicatricial 
strictures, resulting usually from swallowing hot or corrosive liquids, such as 
potash, hydrochloric acid, &c. In such cases there is immediate danger of 
suffocation from implication of the larynx, as well as more or less dysphagia 
from pain and swelling. These troubles, howevei, may be slight and tran- 
sient, and yet after a time cicatricial stricture may appear, or the obstruction 
may be present from the first. 

In cicatricial strictures there is a good deal of muscular spasm present, 
either constantly or from time to time, and this may be much increased by the 
passage of bougies. In some cases it is impossible to pass even a small in- 
strument without an anaesthetic, and yet a fair-sized one may be admitted when 
the child is fully under chloroform. Sometimes at intervals the child is able 
to swallow fairly freely, while at other times the obstruction is almost com- 
plete. The profuse secretion of saliva and mucus is often very distressing. 
Such contractions are most commonly situated high up in the gullet, but they 
may be very extensive. The position of the stricture may be ascertained by 
auscultation during drinking, or by the passage of bougies, 1 after the history 
of the accident and the dysphagia have led to the discovery of the obstruc- 
tion. A careful examination should be made of the oesophagus, to find out 
if possible the calibre, position, and number of the strictures, but bougies 
must be used with the utmost gentleness. We have had a case of perforation 
of the oesophagus and escape of fluid into the pleura in our own experience. 
In a case which we saw with Mr. T. H. Pinder he told us that at one time 
marked improvement in power of swallowing followed entire deprivation of 
all food by mouth ; the child was supported for some days entirely by 
enemata, and it is probable that absence of irritation caused relaxation of 
muscular spasm, though there was a possibility that the relief was due to a 
sloughing off of the edge of the constricting cicatrix at least in part, or it 
may have been merely that there was an interval in the progress of the con- 
traction analogous to that occurring in cases of malignant disease. Mr. Pinder 
suggested that abstinence might also have diminished the size of the pouch 
which forms in these cases above the stricture, and so abolished the valve- 
like obstruction to some extent. 

The best treatment of oesophageal stricture in such cases is usually that 
by gradual dilatation with bougies.'- The drawback to it is that relapse is 

1 In new-born children the distance from the gums to the cardiac orifice is about seven 
inches (Sir Morell Mackenzie). 

2 Keller records thirty-five cases under two years of age with twenty-three cures, im- 
provement in three cases, and five deaths, four remaining under treatment. 



So Diseases of the Digestive System 

\v\-\ apt to occur as soon as the daily passage of the instrument is omitted. 
Forcible dilatation by MacCormac's dilator and internal oesophagotomy have 
been employed ; the former may be useful, the latter is too dangerous. Fail- 
in- these, cesophagostomy may be performed if the stricture is limited to the 
upper part of the gullet, or if not, gastrostomy ; the latter operation is the 
safer and the more generally applicable one. If an operation is to be done, 
it must not be put off too long. As soon as it is clear that dilatation is insuf- 
ficient and the child is losing weight, no further time should be wasted. 
Done early, and done in two stages (Howse), some success maybe expected 
from gastrostomy, and the rest given to the gullet by the operation may 
result in restoration of the canal subsequently (Davies Colley), or it may be 
possible to dilate or divide the stricture by instruments passed upwards 
from the stomach into the oesophagus. For details of the operations we 
must refer to the general text-books. In a case in which we performed 
gastrostomy there was much trouble from regurgitation of the food through 
the gastric fistula. The wound became unhealthy, and the child died of 
abscess between the liver and stomach. 

(Esophageal stricture from congenital syphilis, and obstruction from 
pressure of abscesses outside the gullet or from traction by cicatricial tissue 
around (pericesophageal abscess), are occasionally met with, as in the follow- 
ing case, in which stricture of the oesophagus followed scarlet fever : 

Hannah N., ast. three, had scarlet fever six months before admission. The attack 
was a severe one, with a bad throat and suppuration of cervical glands. She was admitted 
April 4, 1892, with stricture of the oesophagus, severe enough to have prevented swallowing 
solids for some time past. Takes milk and gruel. The obstruction was at the level of the 
cricoid, and even the smallest bougie could not be passed through it. The pharynx above 
the stricture was dilated, causing a protrusion on the left side of the neck. She was able 
to swallow milk and fine sop, and gained weight in hospital. She was taken out, and 
again admitted in the following October, when the symptoms, which had abated, 
became worse upon attempting to swallow some apple. There was then complete 
obstruction, but under chloroform a small catheter '(Xo. 3, English) was passed through 
the stricture, which apparently extended for a considerable distance. When heard of two 
years afterwards, she could eat bread and butter and mashed potatoes very well, but could 
not swallow meat. She was well nourished. 

Swallowing- Foreign Bodies. — It is very common for children to be 
brought with a history of having swallowed a farthing or button, -or some- 
thing of the kind, and much alarm is caused to the child and its friends. 
In many cases the history is a mistaken one, in others the foreign body 
passes into the stomach, gives rise to no symptoms, and is voided in a day 
or two with the motions. 

The only treatment required in such cases is to give the child plenty of 
bread, potatoes, suet pudding, ev_c, to provide a sufficient faecal sheathing for 
the harmless passage of the body. 

In some few instances, however, an angular mass such as a bone, or a 
sharp-pointed object such as a pin, maybe swallowed, and may be arrested in 
the pharynx or oesophagus. In such cases there is usually some obvious sign 
of its presence, such as pain, dysphagia, retching or vomiting ; possibly some 
blood-stained mucus is brought up. Within the last year or so we have had 
four cases under our care in which a halfpenny has been swallowed, and 



Swalloiving Foreign Bodies 81 

in each case it was clearly shown by a radiogram just behind the top 
of the sternum with the faces of the coin antero-posterior. In one instance 
the coin had been six weeks in the gullet, and in none of the cases were 
there any very severe symptoms. In each instance we removed the 
halfpenny by means of the ' coin catcher,' while the child was under an 
anaesthetic ; no trouble followed in any of them. 

If there is no urgent dyspnoea, a careful examination of the fauces should 
first be made, to see if the object is not lodged between the pillars ; failing 
this, the finger should be passed to the back of the throat, and the root of 
the tongue and epiglottis be searched, care being taken not to mistake the 
cornua of the hyoid for a foreign body. If nothing is found, and the site of 
the body can be felt from the outside of the neck, and especially if the mass 
is hard, angular, and insoluble, an attempt should be made to remove it 
with the bristle probang or coin catcher, or failing these, possibly with 
oesophageal forceps, though these are more dangerous. Failing these plans, 
the choice lies between an attempt to push the foreign body on into the stomach 
and the performance of cesophagotomy. The first plan should be followed in 
the majority of cases, and can be best managed by the gentle, steady use 
of a good-sized bougie. It is applicable to instances where the foreign body 
is soft, smooth, and rounded, and not likely to give rise to trouble in its 
passage through the intestines. It must be remembered that a feeling of 
soreness and irritation may remain about the fauces for some time after the 
passage and removal of a foreign body, and may give rise to the belief that 
there is still something there. In cases of swallowing fish bones, and their 
becoming impacted, doses of hydrochloric acid or vinegar and water may be 
given, but the remedy is unpleasant and tedious. An anaesthetic may be 
used to lessen the discomfort of examination. Emetics, as a rule, are not 
good treatment. As in the cases mentioned, skiagrams are of the greatest 
value in many of these cases. 

Oesophagitis. — Infantile oesophagitis, first described by Billard, is a rare 
disease, supposed to be caused by irritation from bad milk, improper feeding, 
or sore nipples. The symptoms are unwillingness to suck, crying and im- 
mediate regurgitation after beginning to suck, and often some tenderness 
about the neck on pressure. The inflammation may be local or general, and 
may give rise to ulcers or sloughing, and possibly to subsequent stricture. 
The prognosis is bad ; the disease may come on immediately after, or even 
exist at birth. It is not likely to be mistaken for anything except congenital 
malformation, in which the obstruction is absolute. Cleanliness, careful 
feeding, and the administration of glycerine of borax in small doses, con- 
stitute the treatment. 1 

Other rare conditions met with are congenital hypertrophy of the mucous 
glands and varix of the oesophagus. 

1 Sir Morell Mackenzie. 



82 Diseases of the Digestive System 



CHAPTER V 

DISEASES OF THE DIGESTIVE SYSTEM {continued) 

Examination of the Abdomen. — Inspection. — The abdomen in infancy 
is proportionately larger and more rounded in appearance than the abdomen 
of adults, and this is at once apparent on inspection as the infant lies stripped 
in its cot or on its mother's lap. An exaggeration of this condition is often 
seen in cases of chronic dyspepsia or intestinal catarrh ; there is great 
distension of the intestines with 'bound wind,' the abdomen being much 
increased, in girth and the skin stretched and shiny. If, as is often the case, 
there is more or less wasting of the fatty tissues, the large abdomen con- 
trasts strangely with the wasted and shrivelled form of the infant, giving it a 
very characteristic appearance. The large liver of the infant is responsible 
to some extent for the disproportionate size of the abdomen. An inspection 
of the abdomen will reveal any enlarged veins on the surface, or the 
presence of large tumours or an excessive amount of fluid in the peritoneum. 
The umbilicus will be examined at the same time, and any hernia or local 
lesion here detected. Instead of a distended abdomen, the condition of 
flatness or retraction may be present, especially if there is acute cerebral 
disease. 

Patpation. — The muscular wall of the abdomen is comparatively thin, 
and less rigid in infants and young children than it is in adults, and con- 
sequently palpation yields more definite results, and is therefore of 
greater value as a means of diagnosis. Thus in young children the edge of 
the liver, an enlarged spleen or kidney, faeces in the colon, a distended 
bladder, a matted and thickened omentum, and much enlarged mesenteric 
glands may be felt by more or less deep pressure by the hand on the 
abdomen. It is needless to say that the conditions are not always 
favourable ; distension of the intestines with gases so as to bulge and distend 
the abdominal walls will necessarily interfere with palpation of the abdomen; 
then, again, a fractious and crying child is necessarily difficult to examine in 
this way. But even under the most unfavourable circumstances, the warm 
hand, laid on the abdomen and firmly pressed in, may detect a tumour or 
some enlarged organ, and information be gained which may be of great 
advantage in making a diagnosis. Even ascertaining the tenseness or laxity 
of the abdominal walls is of importance in forming a diagnosis between 
cerebral and gastric vomiting, as in cerebral disease there is mostly a relaxed 
state of the walls of the abdomen which enables the edge of the liver and 
perhaps other organs to be felt with abnormal distinctness ; while, on the 






Examination of the Abdomen 83 

other hand, in gastro-intestinal disorders there is usually more or less disten- 
sion of the stomach and bowels, the distended organs interfering with a 
thorough exploration of the abdominal contents. Palpation may give 
valuable information with regard to pain and tenderness in the abdomen, 
provided the observer is alive to the fallacies which may arise through the 
fractiousness of his little patient. 

We note here that palpation with the forefinger in the rectum may give 
valuable information in some conditions, as in invagination of the bowel, 
tumour, abscess, &c, in the abdomen. 

V>y percussion the investigator is able to confirm the results obtained by 
palpation, and gain information not otherwise obtainable ; thus he may map 
out by percussion the outline of a dilated stomach, or ascertain the limits of 
fluid in the peritoneum. 

Anatomically the abdomen of the infant differs from the adult's in that 
the liver is proportionately larger in the newly born infant, occupying at 
least half of the abdominal cavity. The inferior limit of the liver is con- 
sequently lower, and the left lobe covers the stomach to a greater extent in 
the infant than in the adult. The infant's stomach, so far as shape is con- 
cerned, does not differ in any important respect from the adult's ; the cardiac 
curvature is perhaps less well marked, and it comes into closer relation with 
the liver and spleen. As a consequence of the thinness of their walls, the 
stomach and intestines are apt to become dilated during infancy from the 
pressure of gases given off from their contents, and to remain more or less 
constantly in a distended state. The large intestines — more especially the 
caecum, ascending colon, and sigmoid flexure — are more movable, and con- 
sequently more easily dragged from their normal position, in infants than 
in adults. This is especially true of the sigmoid flexure, for sometimes at 
an autopsy the sigmoid flexure, if distended with gas or faeces, may be found 
much displaced towards the right side. This must be remembered in pal- 
pating the abdomen, for faeces which from their position may appear to be 
in the ileum or caecum may in reality be in a displaced sigmoid flexure. 

The Dyspeptic Diseases of Infancy and Childhood. — No infant, 
whether fed at the breast or with artificial foods, escapes having indigestion 
in one form or another ; it is certain that sooner or later various dyspeptic- 
ailments will supervene and form no insignificant part of the troubles of an 
infant's life. We have not far to go to seek an explanation of this. The 
alimentary canal of an infant is exceedingly intolerant of any form of irrita- 
tion, while, with very slender resources to fall back upon, it has to perform a 
large amount of work in the digestion of food in order to make good the 
losses incident to life and supply suitable material for the rapid growth which 
is taking place. During the whole of infancy the digestive apparatus is 
worked to its uttermost capacity in digesting the food required for the infant's 
maintenance and growth, and any overtaxing of its powers is very likely to 
be followed by disturbed function. The commonest causes of indigestion 
in infancy are practically the same as those in adults : the appetite perhaps 
is in excess of the digestive powers, and more food is taken than can be 
digested, or the food taken is of an improper quality ; in both rases the 
result is the same, the digestive juices are weakened, the food decomposes 
in the alimentary canal, toxic products are formed, and vomiting, colic, or 

G 2 



84 Diseases of the Digestive System 

diarrhoea occurs. In some cases the vomiting points to the stomach being 
most affected ; in others the passage of loose stools containing undigested 
food, with much flatulence, indicates that the small intestines are involved, 
the large bowel when colic, tenesmus, and an excoriated condition of anus 
are present. In the mild cases there is a deficient secretion or impaired 
quality of the digestive juices so that they are incompetent to digest the 
amount of food taken, decomposition products are formed, which give rise 
to discomfort, until expelled by vomiting or diarrhoea. In the severe or 
more prolonged forms there is a catarrhal condition of the mucous membrane 
which is more or less obstinate in its course. In discussing these dyspeptic 
conditions arising during infancy and childhood, it is convenient to consider 
the prominent symptoms separately, always bearing in mind, however, that 
they are only symptoms of morbid conditions and not diseases. 

Flatulence and colic may be present unaccompanied by either vomit- 
ing or diarrhoea, both breast-fed and bottle-fed babies alike suffering, though 
the latter do so more frequently. It is the result in many instances, perhaps 
most frequently, of the infant taking its food too quickly and in too large 
quantities ; digestion is performed imperfectly, fermentation takes place in the 
small intestines, and gases are formed which distend the bowels. The 
abdomen is distended, the infant is restless and cannot sleep, it is constantly 
crying and tossing about, and if it brings up or passes large quantities of 
flatus, there is much relief. Ease for the most urgent symptoms may be 
found in giving the infant a teaspoonful or two of an equal quantity of lime 
water and cinnamon water, or small doses of carbonate of ammonia and soda 
in peppermint water, or a small piece of the compressed salts known as 
1 soda-mints,' dissolved in a little syrup. It will be necessary, temporarily at 
least, to lessen the amount of food which the infant is taking ; this can be 
done in breast-fed children by giving them some sweetened barley water or 
whey before taking the breast, and not allowing the breast to be given for too 
long or too often. In artificially fed infants the amount of food, especially 
the amount of curd, must be reduced either by dilution with barley water, 
lime water, or by predigesting the curd. Large enemata of warm water 
(10-15 oz.) and hot fomentations to the abdomen will generally relieve the 
severer cases of colic due to flatulence, and a grain of mercury and chalk 
powder combined with half a grain of Dover's powder may be given by the 
mouth. Carbonate of magnesia with syrup of ginger is often useful. (F. 11,14.) 

Vomiting-. — Vomiting is a very common complaint during infancy, and 
babies that vomit are among the most troublesome cases with which we 
have to deal. There is a hypersensitive condition of the mucous membrane 
of the stomach, excessive peristaltic movements take place, and the stomach 
contents are vomited with more or less force. In some of the minor cases 
vomiting is due to overfeeding, or the food is too rich in fat or proteid ; in 
more serious cases there is mostly a gastric catarrh, which is difficult to get 
rid of. The most frequent way in which food is rejected from the stomach 
is by what is termed by mothers ' posseting,' which consists of eructations of 
small quantities of fluid from time to time without any effort, the food 
escaping from the corners of the infant's mouth in consequence of a too 
vigorous peristaltic action of the stomach. Fluid will also frequently 
regurgitate during the eructation of gases from the stomach. In true vomit- 



Vomiting 85 

ing there is more or less retching, and the contents of the stomach come up 
with considerable force. Vomiting is especially common in infants who are 
taking cow's milk, and who are unable to digest the large quantities of hard 
curd contained in the milk, the stomach probably containing much decom- 
posing curd and mucus. The stomach is perhaps dilated and toneless, does 
not completely empty itself, while its contents consist of decomposition 
products. Any milk food on entering the stomach quickly undergoes 
fermentation. Sometimes the vomiting is the result of over-distension, or 
the formation of excessive quantities of gases, or of coughing. The vomiting 
of breast-fed infants is often due to their being given the breast at too 
frequent intervals, or to some other cause, as the ingestion of unsuitable 
food on the part of the mother ; or she may be suffering some great anxiety, 
which is in itself quite sufficient to cause an alteration in the quality of the 
breast milk. Vomiting in infants a few days old may be the result of some 
congenital obstruction at the pylorus. It must also be borne in mind that 
vomiting in infants and children is frequently reflex, and not due to any 
lesion of the stomach, but the result of cerebral disease, as meningitis, or 
tumour, or of the irritation caused by cutting a tooth. Vomiting is some- 
times the first, and for a time the only, symptom in tubercular meningitis, 
and may precede for a week, or even longer, any marked cerebral symptoms. 
Reflex vomiting may at first be entirely undistinguishable from dyspeptic 
vomiting ; the condition of the tongue is no certain guide, and it is only as 
the cerebral symptoms become more marked, the abdominal walls either 
retracted or in a toneless, flabby condition, that a diagnosis can be made. 
In older children the vomiting of an acute gastric catarrh may last for a few 
days, but any long-continued or habitual vomiting is very suspicious of 
cerebral disease. The vomiting of a cerebral tumour is very erratic, comes 
and goes suddenly, there is usually headache and optic neuritis. Hysterical 
vomiting is occasionally seen in girls about puberty. Vomiting is usually an 
early symptom of scarlet fever and also of influenza. 

The treatment of vomiting" must necessarily depend upon its cause. 
Vomiting in the breast-fed infant, provided the mother's manner of life or 
diet is not at fault, is probably the result of too large quantities of milk being 
taken or it is too rich ; it will generally be sufficient to insist upon regular 
hours of feeding at not too frequent intervals, and to give the infant a few 
teaspoonfuls of sweetened lime water before it has the breast, with a dose or 
two of hyd. c. creta to act on the bowels. If this is not successful give the 
infant some whey or barley water for a few meals, while the mother's breasts 
are drawn by means of a pump. Do not be in too great a hurry to wean. 
Vomiting in the bottle-fed infant is more difficult to deal with, especially 
when a gastric catarrh exists. The infant is under these circumstances very 
intolerant of cow's milk, even when largely diluted, the milk being quickly 
curdled in the stomach, and the hard lumps of curd are vomited in masses. 
In'the milder cases it may probably be sufficient to resort to dilution of the 
milk, thus decreasing its richness, or to feed the infant entirely on whey 
or barley water for twenty-four or forty-eight hours. Sterilised milk, 
condensed milk, or desiccated milk is nearly always retained more readily 
than fresh cow's milk by infants who vomit. Whatever food is resorted to, 
great care must be taken that too large quantities are not given at a time or 



86 Diseases of tJie Digestive System 

taken too quickly. In severer cases, where no form of fresh milk is tolerated, 
milk peptonised by the addition of Banger's peptonising powders, or the 

condensed peptonised milk sent out in tins is frequently useful. If the 
vomiting is severe and continued, the bottle must be done away with and 
the infant fed by the spoon or pipette, or a wet nurse may be obtained. An 
alkali, such as carbonate of soda, with two or three grains of pepsine in 
powder, may be given before meals ; or bismuth and nux vomica may be 
tried. Washing out the infant's stomach is often extremely useful, the 
infant ceasing to vomit after the acid mucus and decomposing curd have 
been removed. (F. 15, F. 16.) 

Diarrhoea. — Looseness of the bowels is symptomatic of many different 
disorders and morbid conditions. An attack of diarrhoea frequently ushers in 
scarlet fever, or may be present in all stages of the malignant form ; it may 
accompany typhoid fever ; it is often present in septicaemia, empyema, 
uraemia, peritonitis. The commonest form in children is the result of 
an accumulation of undigested food in the intestines, or of some irritating 
matters taken in the food. Infants at the breast are liable to suffer from 
looseness of the bowels soon after birth on account of the colostrum not 
agreeing with them ; they are also liable to suffer from the taking of im- 
proper food on the part of the mother during lactation ; over-feeding or a 
fit of anger, or other strong emotion on the part of the mother, has been 
known to be followed by diarrhoea in the infant. Artificially fed infants 
are much more liable to suffer than infants at the breast. The difficulty 
with which the curd of cow's milk is digested overtaxes the digestive 
powers, the undigested curd irritates the bowels, and increased peristalsis 
is set up. An intestinal catarrh is soon established, the infant is restless, 
peevish, and cannot be got off to sleep, the abdomen is distended with gas, 
the legs are drawn up, and the infant passes perhaps five or six stools or 
more per diem. A severe chill may give rise to colic and diarrhoea. 

An examination of the napkin shows, instead of the bright yellow homo- 
geneous stools of the healthy infant, green and curdy motions, or one 
consisting of a yellowish or green slimy fluid. The infant is thirsty, takes the 
breast or the bottle vigorously at first, but is soon satisfied and pushes it 
away when offered. The tongue is coated and the mouth is often the seat 
of aphthous stomatitis. Vomiting may be present, but is mostly absent. In 
a day or two the infant begins to waste, the muscles of the limbs grow flabby, 
and the skin hangs about the thighs in loose folds, and the parts about the 
anus and genitals become red and frequently raw. Some infants are liable 
to such attacks especially during hot weather, and the final result may be a 
more or less chronic condition of catarrh, to end finally in general malnutri- 
tion from gastro-intestinal atrophy. Rickets is a very frequent sequence of 
intestinal catarrh. 

Not infrequently the symptoms point to a catarrh of the large bowel, and 
are more of a dysenteric character. Dysenteric diarrhoea may be primary, 
or follow an attack of simple diarrhoea, the general affection passing away 
and leaving a local inflammatory condition in the colon, sigmoid flexure, and 
rectum. The same form of diarrhoea frequently succeeds whooping cough 
and measles. There is distension of the abdomen, with often more or less 
tenderness in the left iliac region on pressure, frequent passage of small 



Diarrhma 87 

liquid stools, consisting largely of mucus, biliary matters, and perhaps blood, 
preceded by much straining and forcing down and frequently followed by 
prolapse of the rectum. Older children often suffer from this form of catarrh 
of the large bowel, passing lumpy mucoid stools, and getting up perhaps 
several times in the night to sit on the vessel, only passing each time a little 
mucus streaked with blood. Dysenteric diarrhoea is apt to become chronic, 
alternately better and worse, until the patient is reduced to a condition of 
wasting. Sometimes dysenteric diarrhoea occurs in epidemics in winter as 
well as in summer. We have known several such epidemics. 

Older children sometimes habitually suffer from what has been termed 
'lienteric' diarrhoea, in which a loose stool is apt to follow the ingestion of 
food. Such children are generally subject to loose bowels, a diarrhceal stool 
following any form of excitement, especially a fright, the immediate cause 
being an exaggerated peristaltic action of the ileum and colon. There is 
often in such cases a catarrh of the large bowel, as evidenced 'by the excess 
of mucus which is passed : phthisical children also may suffer in this way. A 
form of diarrhoea which has been termed ' fat diarrhoea,' from the presence 
of an excessive quantity of fat in the stools, has been described ; it is 
presumably due to catarrh of the duodenum and pancreatic duct. 

In the slighter forms of diarrhoea in infants, where there is not much 
restlessness, distension of abdomen, and not more than four or five loose 
stools during the day, it will be usually sufficient to underfeed them for a day 
or two, and give them some mild laxative, as carbonate of magnesia or 
rhubarb and soda. Infants at the breast may be given a few teaspoonfuls of 
sweetened barley water in lieu of the breast, or after they have been partially 
satisfied at the breast. Bottle-fed children should have a low percentage ot 
proteid in their food, such as a weak cream mixture (see p. 50) if the stools 
are loose and curdy. 

If the purging is at all severe and curdy masses are vomited, or appear 
in the stools, it will be best at once to withhold all milk for a day or two, 
and to substitute some more digestible and less fermentable food, such, for 
instance, as — 

Arrowroot water 2 ounces 

Whey ........ 2 „ 

White sugar I tea spoonful 

or — 

Barley water io ounces 

White of egg ± ounce 

White sugar i or two teaspoonfuls 

Either of these maybe given out of a bottle every few hours, and in amounts 
according to age. Veal broth is also very useful. 

The medicinal treatment in the early stage consists in giving a laxative 
for the first twelve or twenty-four hours. In these cases the diarrhoea is 
probably the result of a congestion of the mucous membrane of the intestine, 
and of the presence of irritating, perhaps putrescent materials, and it is wiser to 
assist elimination than attempt to prevent it by means of opium or astringents. 
To this end emulsion of castor oil or small doses of calomel (£ to £ grain) 



88 Diseases of the Digestive System 

may be given, the latter bein^ preferable if there is vomiting, on account of 
its being more readily retained by the stomach. (F. 17.) 

By the end of twenty-four or forty-eight hours the laxative will have done 
all that can be expected of it, and if the stools are yellow, homogeneous, and 
less frequent, a sedative may now be useful, such as bismuth and small 
doses of opium. (F. 18, F. 19.) 

In the majority of cases of simple diarrhoea the attack is arrested by 
these means — namely, a liquid diet in which milk is excluded or given 
sparingly, and a laxative for a day or two followed by bismuth or zinc. It 
not unfrequently happens, however, that a simple diarrhoea without urgent 
symptoms passes suddenly into the acute or inflammatory form, or, on the 
other hand, it may end in a more or less chronic condition of looseness of 
bowels with marked loss of flesh. As improvement takes place diluted 
milk may be allowed in small quantities, or, what is useful and readily pre- 
pared, milk diluted with twice its bulk or an equal quantity of arrowroot 
water (a teaspoonful to 10 oz.) and sweetened with white sugar. Malt 
extract may be added a few minutes before the food is taken. During 
convalescence, diluted acids with pepsine or astringents are the best remedies. 
(F. 20, F. 21.) 

Constipation. — Constipation is one of the minor troubles which are of 
most frequent occurrence during infancy, and for which the advice of the 
practitioner is sought. Both breast-fed and artificially fed infants suffer, 
though the latter far more frequently and severely than the former. The 
healthy infant passes two or three semi-liquid homogeneous orange-coloured 
stools daily without effort or straining, while some infants appear to have a 
difficulty in defecation from want of expelling power, but at once pass a 
fairly healthy stool if the colon is reflexly stimulated by inserting a small 
suppository into the rectum. In the majority of cases, however, in which 
constipation exists, the stools are dry and pale with an excessive quantity of 
mucus, and an evacuation only occurs once a day, or perhaps once every two 
or three days. There is usually much straining before the stool is passed, 
and perhaps some mucus tinged with blood may accompany or follow- the 
stool. Infants who suffer much from constipation are often anaemic, but 
they are by no means always badly nourished as far as fat is concerned. 

In the majority of cases it is the result of a want of tone in the large 
bowel, which in chronic cases may be dilated, the peristaltic action being 
sluggish and not easily evoked ; perhaps also the intestinal juices are scanty 
and the bile deficient in quantity. In some cases constipation is due to a 
deficiency of fat in the food ; the faeces normally contain fat, and it appears to 
act as a natural purgative. Fluid faeces in the colon seem much more 
readily to excite peristalsis than solid faecal matters. Infants who are con- 
stipated usually have abnormally distended abdomens, and faecal masses 
may often be felt in the transverse and descending colon. In some cases 
constipation is distinctly hereditary ; mothers who suffer much from this 
trouble often have infants who also suffer in this way. It must not be for- 
gotten that narcotics in small doses constipate, and bromides — though in less 
degree — have the same effect. 

Constipation is a frequent trouble in children as well as in infants. Fat, 
rickety children, who are late in walking, very frequently suffer in this way. 



Constipatio7i 89 

In some, constipation and looseness of bowels alternate with each other. It 
mostly, perhaps, occurs in those children where milk in too large quantities 
is given and is not well digested, as evidenced by the large solid pasty 
stools. In older children it occurs in those who take little exercise, and 
who have large appetites ; though in some of these cases it appears to be 
hereditary. If an infant at the breast suffers from constipation, care should 
be taken to first inquire into the diet and habits of the mother or wet nurse. 
An analysis of the milk may be made to determine the amount of fat, it may 
be necessary for the mother to take more in the way of stewed fruits or some 
laxative medicine, such as confection of senna or cascara. In some cases 
the infant's stools may be fairly normal, and the infant appears to suffer from 
a want of expelling power ; this may be overcome by gentle friction of the 
abdomen with the oiled hand, or it may be necessary to reflexly stimulate 
the colon and abdominal muscles by introducing into the rectum a 
small piece of soap or glycerine suppository. In artificially fed infants of 
feeble digestive powers, treatment is often much less successful. The first 
consideration is the diet ; this will probably have to be changed in the 
direction of diminishing the quantity of curd, increasing the amount of fat, 
and adding some form of malted food or extract of malt. The best diet for 
constipation is one which is well digested and which contains the food 
elements in proper proportion. What is wanted is a better tone in the 
large bowel. Oatmeal water, or a small quantity of finely ground oatmeal 
added to each bottle, may have the desired effect. Persistent and carefully 
applied massage to the abdomen by a trained nurse is of much value in 
obstinate cases of habitual constipation. Enemata of glycerine and water 
(3ss~5j) or olive oil are preferable to medicines for habitual use. Glycerine 
suppositories are often successful, or suppositories containing \ — \ grain of 
belladonna may be used. Bitter and nauseous medicines are to be avoided 
as far as possible, for it is more than likely they will not be persevered with 
by the nurse or friends. In many cases two to three grains of car- 
bonate of magnesia or a teaspoonful or two of fluid magnesia given several 
times a day in milk will be all that is necessary, for infants. When these 
fail, small doses of calomel (^i. grain) twice a day for a few days will, if aided 
by enemata, often succeed in bringing about a more satisfactory state of 
things, for a while at least. The aromatic syrup of cascara (B.P.) in doses of 
15 to 30 minims twice a day is often of service. We have often found liq. 
helaline and pepsine or liq. euonymin and pepsine in 1 5 to 20 minim doses 
very useful in the constipation of infants and children. 

In older children the diet must be carefully regulated ; pastry, salt meat, 
and sweets must be forbidden, while oatmeal, green ccoked vegetables, 
stewed fruit, orange juice, stewed prunes and figs, may be given with dis- 
cretion. Sponging with cold water in the morning, plenty of outdoor 
exercise, and only a moderate amount of brain work, should be insisted on. 
Of medicines, the most efficacious are some of the mineral waters, such as 
Rubinat, ^Esculap, Franz Josef, given in warm water or milk overnight or the 
first thing in the morning. Granules containing \ grain of aq. extract of 
aloes or calomel \ grain, with ex. coloc. co. \ grain, are useful ; or A grain of 
res. podophylli. But we frequently find in practice that children will neither 



90 Diseases of the Digestive System 

sweetmeats as cascara chocolate bonbons, or l tamar indien ; lozenges, whi< h 
are pleasant to take, and in some instances at least effectual. 

The B. and \V. tabloids of cascara or cascara comp. or bi-palatinoids 
(Oppenheimer) containing aloes, mix vomica, and belladonna &c. are readily 
taken by older children. In anaemia with constipation the old-fashioned 
mixture of ferrous sulphate and mag. sulph. is very efficacious, but nauseous. 
(F. 22, F. 23, F. 25.) 

Vomiting- — Acute Gastric Catarrh 

If a child is suddenly attacked with vomiting and high fever, the 
probability is strong that the symptoms are due to the onset of some zymotic 
disease, such as scarlet fever or epidemic influenza, or some meat or milk 
poisoning. In infants the symptoms may indicate the onset of the so-called 
* cholera infantum,' or zymotic diarrhcea. In any such case, inquiry must be 
made as to the food the child has taken during the few hours preceding the 
attack, as well as to the possibility of a scarlet-fever infection, and the throat 
and skin must be carefully inspected. But apart from any zymotic disease 
some children seem prone to these fever- vomiting attacks, or ' bilious attacks ' 
as they are sometimes called ; there is headache, nausea, vomiting, and 
fever ; the stomach may reject first some undigested food, then more or less 
bile-stained fluids. In a few days the attack passes off, and the child is 
perhaps better in health than it was before the attack, the vomiting and 
thorough emptying of the stomach having had a distinctly salutary effect. A 
few months after there is perhaps another attack. 

In acute gastro-enteritis, the result of taking some toxines from meat or 
milk, the vomiting, colic, and diarrhcea are often excessive. (See p. 101.) 

Some of these attacks are doubtless due to an acute gastric catarrh, 
brought on by an error in diet or perhaps exposure to cold, in others the 
etiology is quite obscure. Probably in some cases these ' cyclic ' attacks 
are really ' neurotic ' rather than ' bilious,' and we have known cases in 
children who have had attacks of vomiting lasting a day or two or more and 
recurring every few weeks, perhaps for years, but gradually becoming less 
frequent as the children grow older. 

In all cases of acute vomiting it is important to give the stomach a 
temporary rest by avoiding all food or fluids, and giving a little ice by the 
mouth till the vomiting ceases. Rectal alimentation may be resorted to if 
necessary. Veal broth and peptonised milk are the most likely foods to 
be retained by the stomach, but it is not wise to attempt to give food by the 
mouth too soon. Small doses of calomel are useful if the bowels are 
confined ; dilute hydrocyanic acid and also phenacetin are useful in checking 
the vomiting. (F. 26, 27.) 

Acute Gastro-intestinal Infection. Inflammatory or Zymotic 
Diarrhoea. Cholera Infantum 

With the commencement of the warm weather in June or July there is 
an increase in the number of cases of infantile diarrhcea ; and by the time 
the end of July or the beginning of August is reached — especially if the 
weather is close and dry — there is tolerably certain to be, in large cities, an 



Gastro-intestinal Infection 



91 



epidemic prevalence of diarrhoea. It must be within the experience of all 
that the diarrhceal diseases are commoner in summer than in winter, and, 
moreover, that there is more diarrhoea in a hot dry summer than in a 
cold and damp one. The following figures show these facts in a forcible 
manner ; they are taken from the records of the Children's Dispensary, 
Manchester : l 



Mo?ithly Admissions of Cases of Diarrhoea for the year 1880. 



- 


No. of cases | No. of deaths 


Mean lowest 

and mean highest 

temperature 


January 
February . 
March 
April . 
May . 
June . 
July . . 
August 
September . 
October 
November . 
December . 






12 

24 

19 
26 

19 

45 
89 
362 
264 
62 
18 
13 


2 

4 

33 

43 

13 




26-41 F. 

34-52 
34-57 
37-59 
39-64 
47-72 
52-72 
55-75 
51-73 
37-58 
28-53 
33-52 


Total .... 


953 96 





These figures show that there are at all times of the year a certatn 
number of cases being brought for medical aid on account of diarrhoea, 
the number being fairly constant during the first five months and the 
last two months of the year ; with the warm weather of June the number 
increases, reaching its maximum in the hottest weather of August, then 
declining to the normal number in the last two months of the year. The 
year 1880 was a more than usually hot summer for this country, but other 
years show the same relations between the diarrhceal disease of the winter 
and summer months, though in cooler summers the disproportion is not so 
great. 

The same story is told by the mortality tables of diarrhoea in Berlin 
(Baginsky), in New York (Siebert), and also in Baltimore (Miller) ; but in 
these cities the greatest mortality is in July, which is their hottest month, 
while in this country August is usually the hottest month, and the month when 
diarrhoea is most prevalent. The above table bears out the general statement 
that diarrhoea begins to be prevalent whenever the average temperature of 
the twenty-four hours reaches 6o° F., and whenever this average tempera- 
ture is exceeded by only a few degrees, diarrhoea prevails in a widespread 
epidemic. 

A similar table showing the corresponding number of cases of bronchial 
catarrh and bronchitis would show that these diseases were more prevalent and 
1 By ' diarrhoea' are meant those cases in which diarrhoea was a prominent symptom. 



92 Diseases of the Digestive System 

fatal during the cold and damp months of the year than in the warm and dry 
months ; and it has been argued that, just as bronchitis is produced by 
exposure to cold and damp, so diarrhoea is caused by a high temperature, 
giving rise to an intestinal catarrh or to a 'heat stroke.' Hut there are facts 
to show that the explanation is not so simple as this. It is certain that 
a single exposure to a high atmospheric temperature does not give rise to an 
intestinal catarrh ; that hot weather does not at once increase the number 
of cases of diarrhoea, it is only after a high temperature has continued for 
some days ; and that infants at the breast, especially those under three 
months, though exposed to the same conditions of temperature, are only 
exceptionally attacked. 

Summer diarrhoea is much more prevalent and fatal in large cities than 
in country districts, and among the poorest classes who live in back-to-back 
houses in crowded courts and low-lying districts, while it is much less common 
among the better-housed classes of society, especially among those who live 
in the country or suburbs and upon a high and bracing site. 

It is most prevalent between the ages of three months and two years. 
The infants who suffer most are the weakly and dyspeptic ones, who are 
perhaps already suffering from an intestinal catarrh, and who are badly fed 
and improperly cared for — such, for instance, as the illegitimate class of 
infants who are put out to nurse. The infants who suffer least are the 
breast-fed infants ; thus out of nearly 2,000 fatal cases recorded by Emmet 
Holt, only some 3 per cent, had been breast-fed ; the same result has been 
arrived at by the investigations of Dr. Niven of Manchester. This immunity 
is no doubt due to the fact that the milk they take is ' sterile,' and not swarm- 
ing with organisms as cow's milk is apt to be. 

The epidemic prevalence of summer diarrhoea has been attributed, with 
more or less plausibility, to the ingestion of sour milk, unripe fruit, inhalation 
of sewer gas, emanations from the soil ; and possibly each of these may 
contribute to the cases of diarrhoea. That they are not the constant and 
invariable cause is certain, as infants fed on sour milk by no means invariably 
suffer from diarrhoea, and the epidemic is too widespread to be explained on 
the unripe fruit theory ; and, moreover, diarrhoea is not especially prevalent 
in some towns where sewer gas is constantly present in the houses (Ballard). 
While it is certain that the ordinary lactic acid changes occurring in milk 
when it turns sour are not the cause of diarrhoea, yet there is - a strong 
probability that milk often is the vehicle by means of which certain micro- 
organisms or poisons enter the system, and give rise to the symptoms which 
are present in diarrhoea. 

That the diarrhceal diseases are epidemic in hot weather is certain. Are 
any of the forms also infectious ? In some recorded cases it certainly appears 
this has been so. Dr. Bruce Low ' gives an account of four different out- 
breaks of diarrhoea in which it appears that the disease was communicated 
by contagion. It can easily be understood that the stools of infants suffer- 
ing from diarrhoea may infect others. 

There can be little doubt that the immediate cause of infantile diarrhoea 
is an infection of the alimentary canal by various toxine-producing bacteria, 

1 Supplement to the Seventeenth Annual Report of the Local Government Board, 



G astro-intestinal Infection 93 

contained in milk or other forms of food. No specific organism has been 
detected, but the investigations of Booker and others point to the streptococci 
and Proteus vulgaris as being among the chief performers. Some however 
belie ve that the normal bacteria of the alimentary canal, such as B. coli 
communis and B. lactis aerogenes, which are universally present in the stools 
of infants fed on milk, will, under certain circumstances, take on a condition 
of virulency and produce toxines. The entrance of the bacteria into the 
stomach and intestines marks the commencement of the attack, for if the 
conditions are favourable toxines of more or less virulence are formed. The 
action of the toxines is twofold : when absorbed into the blood they produce 
such symptoms as fever, depression of the heart's action, albuminuria, &c, 
while locally they produce irritation of the stomach and intestines, giving rise 
to vomiting and diarrhoea, and later by their corrosive action set up an inflam- 
matory state of the mucous membrane of the lower end of the alimentary 
canal followed by ulceration. 

Symptoms. — The symptoms may supervene suddenly in an infant in 
apparent health, though more frequently an infant is attacked who has 
already suffered for a day or two from intestinal disturbance or has had an 
attack of diarrhoea a week or two before. The first symptom is generally 
vomiting ; this is followed by a loose motion and accompanied by more or 
less fever, at the same time the infant is restless and irritable, the abdomen 
is distended with gas, and the legs are drawn up. The vomiting in the 
severest cases is very distressing, everything taken being rejected imme- 
diately, the vomited matters consisting of undigested food, and subsequently 
of simple mucus tinged with bile ; the stools are watery and consist of undi- 
gested food ; they are usually at first yellow and frothy, or green, containing 
lumps orflocculi of curd. Later, in severe cases, they consist of little else 
than slightly coloured water, or resemble the rice stools of cholera, and as 
the attack becomes more chronic they are of a dirty brown colour and very 
offensive. The tongue becomes coated with a thick white fur, the thirst is 
mostly extreme, the child eagerly taking the bottle or spoon, but vomiting 
immediately afterwards ; there is great restlessness, the child may doze for a 
short time, but rarely manages to get off into a sound sleep. 

The fever is seldom high and mostly intermittent, varying from 99 F. to 
T02 F., in exceptional cases 105 F. or still higher. The stools become more 
and more frequent as the disease advances, sometimes being passed every few 
minutes, perhaps escaping unconsciously or being preceded by a short cry or 
an expression of pain in the infant's face. Very often more or less erythema 
or excoriation occurs about the anus or genitals. After a longer or shorter 
period, according to the acuteness of the case, symptoms of collapse make 
their appearance. There is a change in the infant's face which strikes the 
most casual observer ; the eyes are sunk in the head and kept partly closed, 
the fontanelle is depressed, the face is pallid or of an earthy tinge, the muscles 
of the neck and limbs lose their tonus, and the head rolls about when the 
infant is moved. There is no longer any great restlessness, the infant is 
generally listless and drowsy, and takes little or no notice of its friends. In 
this stage the vomiting usually ceases, the stools become less frequent and 
are smaller, and the abdomen becomes sunken and its walls flabby. 

The further progress of the attack depends upon whether improvement 



94 Diseases of the Digestive System 

sets in ; if so, the diarrhoea ceases, more or less colour returns to the infant's 
face, it takes notice of its friends, and, though still weak, begins to use its 
limbs and take its food. In other cases it becomes more exhausted, it wastes 
rapidly, parasitic stomatitis makes its appearance, and frequently convul- 
sions occur, which quickly bring the end. The fatal event is often preceded 
by the occurrence of cerebral symptoms, such as coma and Cheyne- Stokes 
respiration, a condition which has been termed ' false hydrocephalus ' from 
its resemblance to meningitis, and indeed it is often believed by the friends 
and others that death has occurred through 'water on the brain.' In 
this state the coma is profound, the pupils dilated, and at times unequal, 
the respirations irregular, the child is pulseless, and there may be twitchings 
of the face or limbs. The state of the fontanelle will generally assist the 
diagnosis in deciding whether the cerebral symptoms are due to arterial 
anaemia of the brain, as in false hydrocephalus, or to meningitis ; in the 
former case the fontanelle is depressed below the level of the cranial bones, 
inasmuch as the brain occupies less space than normally, in consequence 
of the arterial system being nearly empty, the result of a failing heart. 

The length of time the disease lasts differs considerably. So rapidly fatal 
are some attacks that the term cholera infantum has been applied to them, 
and indeed in a few instances this resemblance to Asiatic cholera is very 
close indeed. Such cases occur much more commonly in the large cities of 
the continents of Europe and America than in our own cooler climate. 

The following case may be taken as an instance : 

A boy of five years of age was taken suddenly ill with vomiting and purging at i A. M. 
and died at 2.45 P.M. on the same day. When admitted to hospital at 11 a.m. he was 
completely collapsed ; the pupils contracted, the conjunctivas nearly insensible, the lips 
were pallid, the pulse could hardly be counted, the temperature was 104 F. In spite of 
brandy, ammonia, and nitrite of amyl, he failed to rally. The post-mortem examination 
showed the body to be well nourished and rigor mortis strongly marked. The intestines 
were distended with gas, and contained a small quantity of pale gelatinous fluid, the 
mucous membrane of the whole length of the alimentary canal was pink with minute 
extravasations of blood, and the solitary glands were enlarged. The tissues generally were 
pale and dry. The case occurred in August 1880, a summer which was unusually hot, 
and during which zymotic diarrhoea was very prevalent. 

In a few cases, convulsions may supervene during the first few days, and 
bring about a fatal termination. In the majority of fatal cases the duration 
is somewhat longer, perhaps a week to ten days, the infant passes through 
the acute attack, the symptoms then assume more or less of a dysenteric 
character, and it succumbs through exhaustion and inanition from a failure 
of the alimentary canal to recover its normal functions. Many infants who 
escape with life in August, die in September or October from gastro- 
intestinal atrophy, which has followed as the result of the acute attack. 

Complications. — By far the most common complication of acute intes- 
tinal catarrh is broncho-pneumonia, or bronchitis and collapse of lung. The 
symptoms are apt to be latent, but any dyspnoea or high temperature would 
necessarily call for a careful examination of the lungs. Thrombosis of the 
cerebral sinuses occasionally takes place in the later stages, but it is com- 
paratively rare ; the symptoms consist in distension of the veins emptying 
into the cavernous sinus with oedema of the forehead and eyelids ; there 



G astro-intestinal Infection 95 

will also be tonic spasm of the limbs and neck, and convulsions. Albu- 
minuria frequently occurs during acute diarrhoea ; nephritis and uraemic 
convulsions have been described by some authors ; but we do not think the 
convulsions which frequently occur towards the last are uraemic. Peritonitis 
occasionally occurs, hyperpyrexia may also occur. 

Sequela. — Should the infant recover from the acute attack, it is by no 
means certain that complete recovery will take place ; for it is extremely 
probable that gastro-intestinal atrophy may supervene, or a chronic diarrhoea 
remain, the result of chronic catarrh with follicular ulceration of the colon, 
sigmoid flexure, and rectum. In the latter case the symptoms are those of 
dysenteric diarrhoea ; defalcation is frequently accompanied by much pain 
and straining", the stools consist of mucus, often tinged with blood, or are dark 
brown and liquid. The rectum becomes prolapsed, and is sometimes returned 
with difficulty, and the child rapidly wastes. Not infrequently we see children, 
usually under two years of age, who have gone through a severe attack of 
diarrhoea, extremely anaemic, and whose subcutaneous tissues, including the 
face, are ©edematous. In such cases a trace of albumen may be found in the 
urine, but it is usually free from albumen. They have been described by some 
authors as suffering from nephritis. Our own experience is that the kidneys in 
such cases show very little pathological change, and moreover urine is freely 
secreted during' life. This sequela, whatever may be the pathology of it, is, we 
are inclined to believe, the result of ptomaine poisoning. 

Diagnosis. — The principal difficulty in diagnosis occurs in the acute form 
of the disease, as it may be confounded with acute scarlet fever, sunstroke, 
or irritant poisoning, such as from eating poisonous fungi. We have several 
times been requested by a coroner to make a post-7nortem on a child who 
has been seized with vomiting, purging, and high fever, with great depres- 
sion, followed by death in a few hours ; and we have been unable to say 
for certain, from the post-mortem appearance, whether the death has been 
due to malignant scarlet fever or acute inflammatory diarrhoea. The pro- 
blem has been solved in some instances by the occurrence of scarlet fever 
in the same house shortly afterwards. In the majority of cases the appear- 
ances seen in the throat would suffice for diagnosis. The diagnosis between 
sunstroke and acute cases of cholera infantum may be difficult, as there may 
be a high temperature in both ; but in most instances the gastro-intestinal 
disturbance is much more marked in the latter than the former. It must be 
borne in mind that some consider cholera infantum to be really cases of 
\ heat stroke.' 

Prognosis. — Acute intestinal catarrh must always rank as a serious 
disease, not only from its tendency to prove fatal during the attack itself, but 
because it so frequently passes on into a subacute or chronic form of catarrh 
to be succeeded by atrophy. The younger the infant, the more serious the 
prognosis becomes, especially if it has been artificially fed ; in older children, 
though the attack may be severe and the depression produced very great, 
the disease usually terminates favourably. The onset of cerebral symptoms 
is of very unfavourable augury, and the chances are against the infant 
though the case is not hopeless. Convulsions are generally followed by death. 
In those cases in which infants lapse into the chronic stage the prognosis is 
serious, as they are already exhausted by the acute attack. 



g6 Diseases of the Digestive System 

Morbid Anatomy. — If death has taken place early in the disease, the 
body is well nourished and perhaps even plump, but the face retains 
the same expression it had during life, the eyes and cheeks being sunken. 
On opening the body, minute haemorrhages are usually present on the sur- 
face of the lungs and heart, and there is hypostatic congestion at the bases 
of the lungs. The mucous membrane of the stomach and bowels is swollen 
and pink from capillary congestion, the congestion often being present in 
patches, and minute haemorrhages may have taken place. The mucous 
membrane of the large intestine is congested, especially along the summit of 
the folds of the membrane. An excess of mucus is generally present, and 
the contents are liquid. The Peyer's patches and solitary glands are most 
frequently swollen ; the kidneys are pale, the cortex frequently enlarged. 
In the later stages, the body is more or less emaciated, the lungs are semi- 
solid at their bases from the presence of catarrhal pneumonia, the mucous 
membrane of the small intestine is swollen and congested, but the principal 
changes will be noted in the large intestines. Here the mucous membrane 
is generally much congested, especially about the caecum and descending 
colon, there may be superficial ulceration or excoriation at the summits of 
the folds of mucous membrane, or the bowel may be pitted with deep but 
small ulcers from the results of breaking down and discharge of the solitary 
glands. Microscopical examination of the intestines shows a distension of 
the network of capillaries of the villi and mucous membrane, and an exuda- 
tion of leucocytes is mostly present in the submucosa and between the 
tubules or crypts of Lieberkuhn. Numerous micro-organisms are present. 
The solitary glands, especially in the large bowel, are very often in a state of 
softening in their centres, or their contents have discharged, giving rise to 
sharply cut ulcers. 

On examining the brain, no constant or indeed definite lesion is found ; 
in most cases the sinuses are distended with blood or occupied by a firm pale 
clot, but this condition of engorgement appears to be the result of death 
taking place through cessation of respiration, or during a convulsion, and is 
due to mechanical causes from interference with the return of blood to the 
lungs. The symptoms referable to the brain during the last few hours of 
life, coma, Cheyne-Stokes respiration, &c, have been attributed to exhaustion, 
and an anaemic (arterial) condition of brain due to diminished arterial tension. 
The suggestion that they are due to uraemia is improbable, though it is not 
unlikely they are due to the absorption of ptomaines from the alimentary 
canal. Meningitis is extremely rare ; in one case, however, which came 
under our notice, lymph was found about the optic commissures. 

Treat7iient. — The most important part of prophylactic treatment is con- 
nected with the food which the infant takes and the purity of the air which 
it breathes. No weakly infant who is being reared on artificial food and who 
has previously suffered from intestinal catarrh ought, if it is possible to avoid 
it, to remain in the crowded part of a large town during the hot weather, but 
should be sent away to a bracing seaside place, or country quarters should 
be selected among breezy hills. The greatest care should be exercised in 
the selection of pure milk and in its storage before it is taken by the 
patient, as there is little doubt that milk readily absorbs noxious gases, is 
easily contaminated by micro-organisms present in the atmosphere, and 



G astro-intestinal Infection 97 

changes are set up which render it unfit for food. All milk taken by infants 
and children during the summer months should be carefully sterilised in one 
of the milk sterilisers sold for the purpose. Care must also be taken that 
the infant is not given food in excess of its digestive powers, as undigested 
curd or other foods are exceedingly likely to decompose in the alimentary 
canal and give rise to irritation and diarrhoea. The stools, both of infants 
at the breast and bottle-fed children, should be carefully watched, and any 
traces of undigested food or of unusual foulness or looseness of bowels 
should be the signal for lessening the amount of food taken. No infant at 
the breast should be weaned during the continuance of the hot weather, 
and if diarrhoea makes its appearance it ought, if possible, to be returned to 
the breast. 

The indications for treatment when the diarrhoea has commenced, are in 
the first place to give a laxative to clear away all irritating or decomposing 
foods and relieve the congested bowel, and secondly to give food only of 
the blandest character and in small quantities. The first indication can be 
fulfilled by giving castor oil, as long ago advocated by Dr. Geo. Johnson, or 
by a dose or two of calomel. The former may be given in emulsion in com- 
bination with an unirritating antiseptic, as boracic acid or salicylate of soda ; 
the latter helps to prevent decomposition in the emulsion, and perhaps also 
plays a similar part in the stomach in checking putrefactive changes. (F. 28.) 

The oil may be given by itself in half-teaspoonful or teaspoonful doses, 
but it is apt to cause sickness. Instead of the castor oil, especially if there 
is much sickness, small doses of calomel maybe given, and on account of its 
small bulk and tasteless character it is in many respects to be preferred. It 
is better, if the attack is a sharp one, to give it in small and repeated doses, 
especially in weakly infants ; \ to ^ grain may be given to infants and 
young children every two hours, until one or two grains have been given. 
In the course of twelve hours or more, according to the intensity of the 
diarrhoea, all appearances of undigested food will have disappeared from the 
stools, the latter perhaps continuing frequent and watery. Stomach washing 
and irrigation of the large bowel have been largely practised both on the 
Continent and in America, and have the great advantage of removing at once 
the contents of the stomach and large bowel, but no irrigation can reach the 
small intestines. 

Unless the infant be at the breast, all milk or milk foods should be 
stopped, and barley water with white of egg or weak chicken broth substi- 
tuted (p. 8j). The most troublesome symptom at first is the vomiting ; this 
may be constant, following every attempt at feeding, and it will be necessary 
to desist from all attempts for some hours, only moistening the child's 
mouth with a small brush dipped in iced water. Counter-irritation and hot 
applications to the abdomen at this stage are undoubtedly serviceable. For 
this purpose a liniment composed of five drops of oil of mustard to an 
ounce of camphorated oil may be gently rubbed over the abdomen, or 
spongiopiline or several folds of flannel wrung out of water at no° in which 
mustard has been diffused (in the proportion of two tablespoonfuls to a 
gallon) may be applied. 

The medical treatment of acute diarrhoea is unsatisfactory. The vomit- 
ing may continue, the stools in spite of the most careful dieting may be 

H 



98 Diseases of the Digestive System 

loose and frequent, and the child rapidly lose ground. It must, how- 
ever, be borne in mind that the disease is something more than a congested 
irritable state of bowels, in which the contents are rapidly passed downwards 
into the colon and rectum, but the diarrhoea is rather the result of a form 
of irritant poisoning by toxines, which must be got rid of as soon as possible. 
There cannot be the least doubt that in many cases with the cessation of the 
diarrhoea the child becomes no better, but rapidly passes into a condition of 
collapse with cerebral symptoms, due in all probability to toxaemia ; or the 
temperature rises and pneumonia supervenes. 

The drug which has appeared to us the most successful in the vomit- 
ing in the early stages is carbolic acid, the glycerine of carbolic acid being 
given in drop doses every two hours or even oftener. Carbolic acid has a 
sedative action on the stomach, and helps also to check the decomposition 
changes which go on. Other drugs of a similar class, namely salol, creosote, 
resorcin, naphthalin, have been given as antiseptic remedies in the hopes of 
checking the putrefactive changes in the bowel and preventing the formation 
of toxic products. Salicylate of soda has been used by A. Jacobi, of New 
York, and also by Dr. Emmet Holt ; it is given in doses of one to three 
grains every two hours according to age. Resorcin may be given in £ to 
2 grain doses dissolved in water every two hours. But these antiseptic 
drugs are disappointing in the worst class of case. Both bismuth in the form 
of subnitrate and oxide and zinc oxide (F. 30 and 19) are usually of undoubted 
service. Five-grain doses may be given every hour to an infant of twelve 
months. Opium, during the first twenty -four or forty-eight hours, is useless and 
harmful, more especially when there is undigested food in the stools and 
where the vomiting is persistent. After twenty-four or forty-eight hours, if the 
stools continue small and numerous, especially if they approach the 
dysenteric type — the large bowel being chiefly involved — this drug is of 
much value in soothing the patient and diminishing irritability. It is best 
given by enema. The advantage of this method is that it is slowly 
absorbed and its topical effects are useful ; one or two enemata of laudanum 
during the twenty-four hours will mostly relieve the irritative diarrhoea, when 
accompanied by straining and colicky pains, without the necessity of 
omitting or altering the medicine given by the mouth. Two to five drops of 
laudanum may be given in warm decoction of starch per rectum to an infant 
of six months to twelve months, the effects carefully watched, and repeated 
in the course of six to twelve hours if necessary ; -.^ of a grain of morphia 
may be given subcutaneously to a child over three years of age ; or Dover's 
powder may be given by the mouth, \ grain every three or four hours, or 
oftener if the pain and griping are severe. If there be much fever, tepid 
sponging, or in cases of greater severity sponging with ice-cold water, may 
be practised. 

Stimulants may be required from the first, but it is wise to reserve them 
for a later stage, especially as they are apt to give rise to sickness. Brandy, 
a sound port, or champagne, is the form of alcoholic stimulants most useful, 
and they are usually required to be given freely in the later stages if collapse 
is threatened. Ammonia, camphor, and musk are valuable remedies if 
symptoms of collapse have made their appearance. Camphor may be given 
in the form of spirits of camphor, three or four drops every second hour ; or 



Acute Ileo-colitis 99 

musk. (F. 29.) Camphor and musk are not agreeable medicines to take, 
and are apt to cause nausea. 

Irrigation of the large bowel is certainly useful in severe cases, especially 
in the later stages. The ulceration and inflammation are mostly below the 
caecum, and can be reached by fluid injected per rectum. A soft rubber 
catheter is passed some six or eight inches into the rectum and attached to 
a Higginson's ball syringe. Twenty to thirty ounces are injected so as to 
get as high up as possible ; the injection may be continued, allowing the fluid 
to flow back by the side of the catheter. We should not be inclined to 
irrigate the large bowel more than once a day or twice at the most, as to 
disturb the child too much is prejudicial. 

Even when convalescence is established great care must be exercised 
for many weeks in the management of the patient ; the child is certain to 
be left with impaired digestive powers, and liable to gastric or intestinal 
disturbance. A severe attack will often affect the child's health and 
development for many months, so that it is late in talking or standing- 
alone, and at 18 months or two years of age resembles a child of 12 months 
old or less. Moreover, the diarrhoea may become chronic or return in a 
subacute form, and a child may thus be lost who has managed to struggle 
through the primary attack. The diet during convalescence requires the 
most extreme care, and a return to milk diet should not be allowed until 
there is evidence of much improved digestive powers. Broths and beef tea 
made with barley or some light starchy food, meat juice, scraped underdone 
chops, whey, and Mellin's Food, may be given in moderation. 

The mineral acids, pepsine wine, decoction of pomegranate bark, the 
vegetable bitters and astringents, will be useful as the child improves. 

Summary. — Place the child in the coolest room of the house, and sponge 
frequently if there is much fever. 

Stop all forms of milk food, giving barley or arrowroot water with white 
of egg y and veal broth ; if there is much vomiting stop all food for some 
hours. 

Apply hot fomentations or counter-irritation to the abdomen. 

Give castor oil or calomel till all undigested food has disappeared from 
the stools, followed by salol, zinc, bismuth, or carbolic acid. Later, if there 
is much restlessness or colic, give opium by the rectum. In severe cases 
brandy or other stimulant will be required, but it is apt to cause vomiting. 

In infants at the breast lessen the quantity of milk taken and give some 
barley water. 

Acute Ileo-colitis. Dysenteric Diarrhoea 

Diarrhoea of a dysenteric character is sometimes secondary to acute 
catarrhal diarrhoea, or it may follow measles, whooping cough, or other 
zymotic disease. In these cases it is mostly chronic or at the most subacute. 
There is straining at stool : the evacuations contain much mucus and are 
streaked with blood. Prolapse of the rectum is common. In some cases, 
which occur almost entirely in older children, ileo-colitis is an exceedingly 
acute and fatal disease. Cases of this description have been recorded by 
Henoch, Goodhart, and Eustace Smith. The onset is sudden, with vomiting, 

h 2 

LofC. 



ioo Diseases of the Digestive System 

colic, and fever, the latter usually not high ; there is much straining at stool. 
followed by the passage first of faecal matters, later blood and mucus only. 
There is mostly some abdominal tenderness, and in some instances a purpuric 
or petechial rash on the skin. There is certain to be great depression and 
rapidly increasing weakness. There is often delirium at night. At the 
autopsy the last foot or so of the ileum is found to be involved, while the 
changes are more marked in the colon, but most of all in the sigmoid flexure 
and rectum. The mucous membrane is swollen and intensely injected with 
patches of thin membranous exudation, or if the child has lived some days 
there is ulceration of a superficial character. The etiology of these cases is 
obscure. The possibility of meat poisoning must be kept in mind. They 
occur in the hot weather of summer, but their occurrence is not limited to this 
time. One of our cases occurred in April, at the height of an epidemic of 
influenza. (See below.) 

In one case coming under our notice in a girl of twelve years, who was 
admitted to hospital under the care of our colleague, Dr. Hutton, the attack 
commenced with vomiting and diarrhoea, followed by delirium, petechia- on 
the skin, and bleeding from the nose. She was admitted to hospital on the 
sixth day of her illness in a collapsed condition, with a pulse of 190 and a 
temperature of 102 F. ; she passed loose stools containing some hard lumps 
with blood and mucus ; later, the epistaxis again supervened, the tempera- 
ture rose to 104 F., and she died exhausted on the ninth day of her illness. 
The post-mortem showed the folds of the mucous membrane of the colon to 
be of an ashy-grey colour with well-defined ulcers varying in size from a pin's 
head to half an inch in diameter : all the changes were more marked below 
the sigmoid flexure. 

In another case of a somewhat similar nature coming under our care, 
the symptoms so closely resembled those of an invagination of the intestines, 
that an exploratory incision was made into the abdominal cavity. Cases of 
intussusception are not infrequently diagnosed as ' dysentery,' but it is rare 
for the opposite mistake to be made. The case was shortly as follows : 

Acute ileo-colitis— Death. — A boy of nine years of age was suddenly seized (April 22, 
1891) with pain in the abdomen whilst at school, followed by the passage of blood and 
mucus by the bowel ; he continued in this way during the succeeding night. He was 
admitted to hospital next day, and, in spite of fomentations and opium, he passed twelve 
stools, consisting almost entirely of blood and mucus. Temperature 99-100° F. April 
24. — The tenesmus and bloody stools continued, in spite of large enemata of warm 
\\ater ; the latter brought away a small quantity of faecal matters . No tumour could be 
felt ; the abdomen was not distended nor tender to the touch. Temperature 97-99 '6° F. 
In the evening, as no improvement had taken place, and the boy seemed rapidly sinking, 
it was decided to explore the abdominal cavity, in order to relieve an invagination of the 
bowel if present. This was done ; but no invagination was found, only an intensely con- 
gested colon. Death followed about eight hours after. At the post-mortem the stomach 
and small intestines, to within twenty inches of the caecum, were found normal ; the last 
foot or two of ileum was found congested, with patches of thin membranous exudation. 
The mucous membrane of the colon, sigmoid flexure, and rectum was intensely injected, 
the changes in the lowest parts being most marked, the rectum being haemorrhagic. There 
were patches of thin membranous exudation, but no ulcers. 

These acute cases of dysenteric diarrhoea appear to occur in children of 
over eight or nine years rather than in younger children. 



Meal Poisoning 101 

Diagnosis. — Tenesmus, with passage of blood and mucus by the bowel, 
in an infant under a year old, should certainly suggest intussusception rather 
than ileo-colitis ; and a careful exploration of the rectum and palpation of 
the abdomen should certainly be made. In older children these symptoms 
indicate ileo-colitis rather than invagination ; fever, delirium, vomiting, also 
point the same way. 

Treatment. — In acute ileo-colitis only the blandest food should be given, 
such as arrowroot, veal broth, or white of egg mixture, and if there is vomit- 
ing, the less food given the better. Hot fomentations containing opium 
should be applied to the abdomen, and every effort made to allay the inflam- 
matory condition of the colon by small starch and opium enemata. Five to six 
ounces of warm starch mucilage and boracic acid with 10 minims of laudanum 
may be administered to a child of ten years. Anything that can possibly 
irritate, such as purgatives or indigestible food, must be avoided, as likely to 
increase the peristalsis and tenesmus. Stimulants are certain to be required 
sooner or later. In mild or chronic cases irrigation of the bowel is often of 
the greatest service. Thin starchy mucilage may be used with lac bismuthi, 
and the amount employed should be sufficiently large to reach the caecum. 
Laxatives, as rhubarb and soda or castor-oil emulsion, are also useful in the 
early stages. Great care must be taken in the diet, and all rich foods 
avoided. 

XVIeat Poisoning-. Infection with Gaertner's Bacillus 

Under this head we refer to the acute gastro-intestinal disturbance which 
follows the ingestion of some form of animal food which is infected with the 
Bacillus enteritidis, first described by Gaertner. Besides this bacillus and its 
varieties other organisms have been described (B. botulinus), but Gaertner's 
is by far the most common. The diseased animal is usually either the cow, 
calf, or pig, and the infection of human beings is the result of eating imperfectly 
cooked beef, veal, veal or pork pies, sausages, and in some cases raw milk. 
No cases appear to have occurred after using mutton. An exposure of one 
minute to a temperature of I58°F. is sufficient to destroy Gaertner's 
bacillus, and the toxines associated appear to be destroyed by a boiling 
temperature (H. E. Durham). 

The infection is due to the ingestion of the bacillus itself and the consequent 
development of toxines in the system, and not to the ingestion of the toxines 
themselves : in all fatal cases the bacilli have been found (H. E. Durham). 
The animals appear to have suffered from septicaemia, diarrhoea, and localised 
suppurations. 

The symptoms set in within a few hours, and include rigors, vomiting, 
diarrhoea, with excessive griping and sometimes blood in the stools, fever 
often high, followed in severe cases by subnormal temperature, and marked 
collapse with weak irregular action of the heart. Herpes occurs in some 
cases. 

In an epidemic which we had an opportunity of observing, it was the milk 
which was at fault. Upwards of 160 individuals were attacked within a few 
hours of one another, in several families as many as twelve, the children 
suffering the most. All the families were supolied with milk from the same 



102 Diseases of the Digestive System 

farm. The outbreak was investigated by Dr. Niven, who traced the out- 
break to a cow suffering from inflammation of the udder. 

The diagnosis of the cause in such cases is aided by the possibility of 
tracing the cause of the illness to some form of food such as veal or pork 
pies, sausages, milk, &c. It must be borne in mind that the meat or milk is 
not obviously bad or stale, and only a bacterial examination by an expert will 
prove it to be at fault. Blood should be taken from the individuals attacked 
for 'serum reactions,' and forwarded to an expert. It must be remembered 
that influenza may sometimes give rise to a febrile gastro-intestinal disturbance, 
but the fact that many people are attacked within a few hours of one another, 
and then no others are attacked, would arouse the suspicion of meat or milk 
poisoning. 

The treatment is practically the same as already given under Gastro- 
intestinal Infection. The intense griping may require full doses of opium 
for its relief. 



io3 



CHAPTER VI 

DISEASES OF THE DIGESTIVE SYSTEM — {continued) 

Chronic Gastro-intestinal Catarrh. Gastro-intestinal Atrophy 

In some cases a gastric catarrh exists with but little evidence of the intes- 
tines being in any way affected, and in other cases the intestines may be the 
only part of the alimentary canal which appears to suffer ; but in perhaps 
the majority of cases, especially in infants and small children, there is no 
sharply defined limitation between the two, the whole of the alimentary canal 
appearing to be involved. 

The terms chronic vomiting-, chronic diarrhoea, simple atrophy, 
marasmus, malnutrition, athrepsia, are sometimes applied, according to 
the most prominent symptom which is present ; thus, chronic vomiting is 
the most marked and striking symptom which may be present in catarrh of 
the stomach ; diarrhoea is mostly present, or at least more or less looseness 
of the bowels, in the early stages of an intestinal catarrh, though the latter may 
exist without any marked diarrhoea, or in the later stages* there may be con- 
stipation. If the only marked svmptoms are dyspepsia and wasting, then 
the term simple atrophy has been applied. In all these conditions, while 
the symptoms may differ, the anatomical groundwork is the same — namely, 
a chronic gastro-intestinal catarrh, which in later stages passes into a gastro- 
intestinal atrophy. 

Thus, an infant soon after birth, or perhaps when a few months old, 
suffers from repeated and frequent vomiting, or it suffers from diarrhoea, or 
if these are absent there are other chronic dyspeptic troubles, such as flatu- 
lence and colic ; it fails to thrive and gradually wastes, and after a more or 
less protracted illness, during which the wasting becomes extreme, it dies 
exhausted or is carried off by some intercurrent disease. In some cases the 
course is very short, perhaps only a few weeks, but in the majority the 
disease is chronic and the infant lives for months, suffering constantly from 
dyspepsia, unable to digest its food, and wasting to a mere skeleton. The 
less severe cases, especially if they come under treatment, gradually improve, 
and after months of the most caretul feeding and nursing completely recover, 
though such cases usually become rickety or are otherwise weakly. Recovery 
is only possible during the earlier stages ; if the catarrhal stage has passed 
on into one in which there is advanced atrophy of the mucous membrane 
of the stomach and intestines with the secreting glands, recovery is hardly 
possible. 



104 Diseases of the Digestive System 

Experimental research has shown that in these cases there is a diminution 
in the amount of hydrochloric acid and pepsin secreted, while there is an 
excessive formation of mucus, lactic, acetic, and butyric acids. Much gas is 
given off from the decomposing food. 

This gastro-intestinal atrophy rarely occurs in children over 18 months of 
age, and indeed is most common in infants under 6 months. Older children 
suffer from chronic intestinal catarrh, which rarely goes on to atrophy, though 
it is frequently the precursor of tuberculosis of the mesenteric glands. 

In the majority of cases, chronic gastro-intestinal catarrh is the result of 
improper feeding and unfavourable life conditions. Infants who come of a 
healthy stock and are nursed at the breast of healthy mothers rarely, if ever, 
suffer from it. It is the infants who are fed from the first on cow's milk or 
the various forms of starchy foods that chiefly suffer. The infant may go 
on fairly well for the first few weeks or more, suffering more or less from 
dyspepsia ; then comes an attack of diarrhoea or vomiting, and forthwith it 
begins to go downhill ; no food seems to suit it, however often changed, and 
it never recovers its digestive powers, which appear to have been hopelessly 
damaged. Some infants appear to get on fairly well till they suffer from an 
attack of broncho-pneumonia, or measles, or whooping cough, which they 
survive only to begin gradually to waste. In some few instances, more 
especially in dispensary practice, atrophic infants may be seen of a few 
months old, who have been, according to their mothers' accounts, entirely 
breast-fed. In these cases the infants have been congenitally weak or pre- 
mature, and probably the mother's milk has been deficient in quality and 
quantity, and they have been exposed to all the insanitary conditions which 
prevail in the crowded dwellings of the poorest and most ignorant of our 
citizens. 

Symptoms. — Infants. — The history which is generally obtained from such 
cases is that they were suckled for a few weeks or months after birth, then 
the mother had to go to work or her milk failed, and the infant was made 
over to a friend or hireling to be artificially fed, and from this time it began 
to waste. On cross-questioning the mother or caretaker, it is found that it has 
been fed on sopped bread or biscuits, because cow's milk did not appear to 
satisfy it, or it vomited the milk curdled, and it has constantly suffered from 
colic, vomiting, or more commonly diarrhoea. On the other hand, there is 
sometimes constipation, but this usually has been preceded by. diarrhoea ; 
the diarrhoeal symptoms being most marked in those suffering during the 
summer months. If the symptoms be analysed, three stages in the course of 
the disease may be recognised as first clearly pointed out and emphasised by 
Parrot, whose description of these cases under the name of athrepsia leaves 
nothing to be desired. The early symptoms or first stage are those of a 
simple gastric or intestinal catarrh, in the second the progressive wasting be- 
comes the prominent phenomenon, and in the last stage the infant passes into 
an exhausted condition in which cerebral symptoms make their appearance. 
First stage. The infant suffers from a simple diarrhoea or looseness of the 
bowels ; the stools, instead of being bright yellow and homogeneous, are 
liquid, curdy, and often green in colour, or contain an excess of mucus ; 
sometimes they consist almost entirely of stinking decomposing milk ; the 
abdomen is distended with gas and remains constantly in this condition, the 



Chronic Intestinal Catarrh 105 

tongue is coated, and patches of aphthous stomatitis appear in the mouth. 
The infant is restless, constantly whining, and will not sleep at night. Frequent 
vomiting may be a prominent symptom, the milk being returned curdled. 
The tissues become flabby, and then wasting commences. In the second 
stage all the symptoms are intensified and the characteristic wasting becomes 
manifest. The stools for the most part are loose and frequent, and consist 
of undigested food, being often pale and putty-like, with a peculiar odour ; 
at other times they are of a dark brown colour from the presence of altered 
bile. The infant is mostly voracious, liquid food does not appear to satisfy 
it, and by the mistaken kindness of its friends it is fed with sopped bread 
or some thick food, a diet which has the great merit in their eyes of keeping 
it quiet for a longer time than liquid food or diluted milk ; at times it cries 
incessantly, hardly ever appearing to sleep or only dozing for a short time 
unless under the influence of a ' soothing syrup ' supplied by its nurse. The 
mouth becomes the seat of parasitic stomatitis, the skin is harsh and dry, 
small boils or a lichenous rash make their appearance, the buttocks and 
genitals are raw and excoriated. Its temperature is below normal, the feet 
and hands are congested, the face has a pallid earthy tint, and a sickly lactic 
acid smell is given out from the body, especially the abdomen. The wasting 
is extreme, the face being shrivelled, the skin wrinkled and hanging in folds 
about the thighs and arms. In the third stage the infant passes into a 
moribund state ; it is too feeble to cry loudly, it is heavy and drowsy, 
taking little notice of anything. It becomes more and more somnolent, and 
death ensues, probably preceded by muscular twitchings, strabismus, or 
general convulsions. 

If we analyse the principal symptoms of the disease, we shall find that 
sometimes one symptom, as diarrhoea, sometimes another, as vomiting, is the 
most prominent. In the majority of the cases there is more or less diarrhoea 
throughout the whole course, so that such cases would come under the cate- 
gory of chronic diarrhoea, or this chronic condition may alternate with the 
acuter forms. The stools at first are yellow, liquid and frothy, with fiocculi 
of semi-digested curd ; later they become green, the acid contents of the 
intestines acting on the bile pigments ; when the diarrhoea has become chronic 
the stools are either liquid and of a dirty brown colour, or more often, 
especially if milk is being taken, they are white and semi-liquid, the bile 
pigment having disappeared, and they consist of decomposing foul-smelling 
curd and mucus. Sometimes the stools consist almost entirely of mucus, 
the mucous membrane both of the small and large intestine secreting large 
quantities ; the child is constantly passing stools of mucus and undigested 
food. 

In some cases chronic vomiting- is the most troublesome symptom, 
there being no diarrhoea but sometimes constipation. Cases of chronic 
vomiting with the consequent malnutrition are at times most difficult to deal 
with. So great is the irritability of the stomach that everything is rejected, 
either immediately after being taken, or after the lapse of perhaps half an 
hour. Diluted milk, peptonised preparations, meat juice, cream, and a variety 
of patent foods are tried one after another, separately or mixed ; each change 
only ends in disappointment, the infant becoming more and more wasted. 
Under such circumstances among the poorer classes the infant is given 



106 Diseases of the Digestive System 

some thick food, as sopped bread or corn flour. Vomiting in many cases 
appears to be the result of the rapidity with which cow's milk is coagulated 
in the infant's stomach and of the hard lumps of curd which are thrown down, 
this occurring even where the milk is reduced to one part of milk to five of 
water. In other instances it appears to be due to the rapid changes occur- 
ring in the sugar of milk, lactic acid being formed ; the contents of the 
stomach are rejected, having a strong smell of sour and decomposing milk. 
In the catarrhal condition of the mucous membrane of the stomach much 
mucus is formed, while the gastric juice is weak, but its curdling power 
undiminished. Many such cases go from bad to worse, no food appearing to 
agree, all forms coming up alike. 

As the child wastes the skin becomes rough and harsh and hangs in folds 
upon the limbs and trunk, and very frequently, as the anaemia increases, the 
face, hands, and feet become cedematous. This oedema is due to anaemia 
rather than to any kidney complication. An erythematous rash is apt 
to make its appearance about the anus in those cases where there is much 
diarrhoea, and spread over the perineum and thighs. 

It must not be forgotten, in a case of constant vomiting, that it may 
be due to cerebral disease or some congenital defect. The prognosis in 
chronic vomiting is unfavourable if it commences in an artificially reared 
infant, and becomes thoroughly established, and is associated with progres- 
sive wasting. 

Complications. — Broncho-pneumonia is very common. Tuberculosis of 
the mesenteric or mediastinal glands may occur, or there may be a more 
general distribution of tubercle throughout the body. It must be borne in 
mind that it is only in the more severe and neglected cases that intestinal 
catarrh passes on into atrophy ; in the majority of cases the course of the 
disease is intermittent, sometimes better, at other times worse, and as the 
child grows older the symptoms of rickets become grafted on to those of a 
chronic catarrh of the bowels. 

Older Children. — A chronic intestinal catarrh is not so serious a disease 
in children over two years of age as in infants, as it is rarely followed by an 
atrophic condition of the glandular apparatus of the stomach and intestines, 
but takes rather the form of habitual indigestion than anything else. It is, 
however, apt to be exceedingly chronic in its course and to be followed by 
various evil consequences, the most serious of which is tuberculosis of the 
lymphatic glands, or there is a constant state of health below par, which in 
itself is a source of danger. Chronic catarrhal affections of mucous mem- 
branes, either of the nose, mouth, respiratory tract, or intestines, are ex- 
ceedingly apt to be followed by swelling and caseous degeneration of the 
lymphatic glands, with which the mucous membrane is connected. The 
intestinal lesion finds its origin for the most part in unsuitable food ; the 
mucous membrane of the stomach and bowels is kept in a constant state of 
irritation by food which is too great in quantity or of too indigestible 
character. Weakly children are especially apt to suffer, particularly those 
who are brought up in our large cities and whose time is spent either indoors 
or playing in the street. Children who suffer habitually from rhinitis, 
chronic tonsillitis, or chronic disease of the strumous type, are the chief 
sufferers from chronic gastro-intestinal catarrh. It is very common in 



Chronic Intestinal Catarrh lOJ 

rickety children. Both the children of the well-to-do and of the poor classes 
suffer. 

Symptoms. — There is habitual indigestion with perverted appetite, the 
child refusing its bread and milk and craving for ' tasty ' bits from its parents' 
table, or altogether refusing its meals unless its food is highly seasoned ; at 
other times the appetite is excessive. The abdomen is invariably rounded 
from the constant distension of the stomach and intestines with gas given off 
from the decomposing half-digested food. This distension is very frequently 
accompanied by more or less pain. The face is generally pale with 
dark areolae around the eyes, fat is absorbed as the disease progresses, the 
muscles become flabby, and the emaciation of the child contrasts markedly 
with its large tumid abdomen. Such children have usually coated tongues, 
at other times the tongue is red and glazed, showing the enlarged fungiform 
papillae more distinctly than usual and resembling the ' strawberry tongue ' 
of scarlet fever. Sometimes the surface has a worm-eaten appearance, 
being coated with a thick fur except in irregular sinuous patches where the 
surface is red and glazed. The bowels are generally confined, the stools being 
frequently pasty with much mucus ; there are apt to be intercurrent attacks 
of vomiting and diarrhoea. There is very frequently more or less feverish- 
ness at night, especially in the subacute cases. Headaches are common, 
there is often restlessness at night, grinding of teeth, and night terrors. Some- 
times when the disease is subacute, and there is some feverishness towards 
evening, the symptoms resemble mild typhoid fever and constitute what at 
one time was called 'infantile intermittent fever.' It is important to bear in 
mind that subacute intestinal catarrh may be present with an evening ex- 
acerbation of temperature as the principal symptom and with no vomiting 
or diarrhoea. An intermittent fever during early childhood with no pulmo- 
nary symptoms is probably, if typhoid can be excluded, due to an intestinal 
catarrh. It will not fail to be noticed that diarrhoea is a prominent symptom 
in the majority of cases of infants suffering from chronic intestinal catarrh, 
while in older children not only is the diarrhoea not present, but there is 
usually constipation. The explanation of this is perhaps not very clear, but 
it must be borne in mind that those cases where diarrhoea is present and 
excessive are more acute in character and run a more rapid course than those 
where the bowels are less irritable ; there is also more likely to be diarrhoea in 
the early stages where the mucous membrane is congested, than in the later 
stages where the bowels have become more tolerant of irritation and the 
muscular walls wasted through long illness. 

In some cases of intestinal catarrh, more particularly when it complicates 
or follows whooping cough or measles, there is an excessive formation of mucus 
from the intestinal walls, especially the large bowel ; Dr. Eustace Smith 
has called special attention to these cases under the name of ' mucous 
disease.' The bowels are usually loose, the stools consisting largely of 
mucus, or an aperient may bring away large quantities of mucus. In the 
worst cases, when this form of disease complicates whooping cough, the 
prognosis is bad. 

Diagiiosis. — The disease most likely to be confounded with chronic intes- 
tinal catarrh is tuberculosis of the mesenteric glands, or the early stages of 
tubercular meningitis. During the first three or four years of life, it happens 



108 Diseases of the Digestive System 

very frequently that infants or young children are thought to have ' consump- 
tion of the bowels,' because they have capricious appetites, ' pot-bellies, ; and 
have lost much flesh, when in reality they are suffering from a chronic intes- 
tinal catarrh. That the diagnosis is often difficult is only what is to be ex- 
pected when it is remembered that an intestinal catarrh of more or less severity 
is the exciting cause of mesenteric tuberculosis ; and in an advanced case, it 
may be quite impossible to say if a tuberculosis of the glands has supervened. 
Mesenteric disease is, however, much less common than simple intestinal 
catarrh, and is infinitely less so during the first six months of life than gastro- 
intestinal atrophy. Any evidence of tubercle in the lungs, or enlarged veins 
on the surface of the abdomen, or the detection of rounded masses by palpa- 
tion in the abdomen, would favour a diagnosis of tubercular disease. In 
older children the fact that those suffering from intestinal catarrh grind the 
teeth, are restless at night, are subject to night terrors and headaches, is 
sufficient for most parents to become alarmed, fearing that the child is com- 
mencing with tubercular meningitis. 

Morbid A?iatomy. — Chronic Gastro-intesiinal Catarrh. — In the early 
stages there is swelling, and injection of the mucous membrane of the 
stomach, and small and large intestine. The surface is grey, streaked with 
red, and there is an excess of mucus : the changes are usually most 
marked in the ileum and colon, especially about the sigmoid flexure ; in 
these places the solitary glands are enlarged, the mucous membrane is 
raised in folds, and often much injected, and follicular ulceration may be 
present. The microscopical appearances somewhat resemble those already 
described in acute catarrh. The surface of the mucous membrane of the 
stomach is covered witn masses of leucocytes and micrococci embedded in 
mucus. The capillaries are everywhere distended, the gastric glands are 
separated from one another by columns of leucocytes effused between them, 
the whole mucous membrane is swollen, and the muscular layer thickened. 

Similar changes are seen in the intestines, leucocytes are present in large 
numbers in the submucosa and between Lieberkuhn's glands ; the latter are 
compressed and finally disappear, so that in places only masses of round cells 
are seen taking the place of the glands. A stage of atrophy succeeds that of 
chronic catarrh, and the appearances presented are those of a wasting of the 
mucous membrane, and a destruction of the secreting glands. The chronic 
swelling of the mucosa, and infiltration with leucocytes, have led to a wasting 
and cicatrisation of the tubular glands ; but death usually takes place before 
this stage is reached. 

In gastro-intestinal atrophy the stomach and intestines are distended 
with gas, the former is frequently dilated, the mucous membrane is every- 
where pale, the intestines are thin and translucent. This is especially 
marked in the more advanced cases, the intestinal walls are exceedingly 
thin, the solitary glands and Peyer's patches are wasted and have almost 
disappeared, with perhaps brownish spots or streaks where minute haemor- 
rhages have taken place. These appearances will be varied with those of 
chronic catarrh according to the amount of atrophy that has taken place. 
The microscopical appearances show the mucous membrane of the stomach 
to have undergone wasting, being reduced to perhaps one-quarter its normal 
thickness. The gastric glands in places have completely disappeared, in 



Chronic Intestinal Catarrh 109 

other places they are compressed and partly destroyed by round cells and 
young connective-tissue fibres. In the small intestines the appearances 
will be those of chronic catarrh, or these with the addition of destruction of 
the glandular apparatus. The tubular glands in places are atrophied or 
are compressed or dilated by a connective-tissue growth, the villi have 
completely disappeared, or only their remains are present, the solitary glands 
are atrophied or have disappeared. Similar changes may be found in the 
colon. Parrot has described various other lesions in the alimentary canal 
of infants dying within a few weeks of their birth ; such as a spread of the 
parasitic growth from the mouth to the stomach and intestine, usually the 
caecum. The same author has found minute circular ulcers in the stomach, 
from which haemorrhage has taken place, less often larger and irregularly 
shaped ones ; he has also seen the mucous membrane of the stomach to be 
the seat of a diphtheroid exudation. In the later stages, when the blood is 
profoundly altered, thrombosis of the renal veins, pulmonary veins, or 
sinuses of the brain may take place. Fatty degeneration {steatose of Parrot), 
softening, or meningeal haemorrhage, may take place in the brain. The 
kidney may be the seat of uric acid infarcts. 

Treatment. — The treatment of chronic gastro-intestinal catarrh in infants 
consists principally in careful feeding ; the blandest and least irritating forms 
of food must be selected, while frequent weighings of the infant should be 
resorted to in order to ascertain if any progress is being made. In infants 
under four months a wet nurse should be obtained if possible. Where 
there is much diarrhoea, milk must be used sparingly or altogether omitted 
for a while, as the hard curds formed in the stomach are beyond the digestive 
powers of the weakened stomach and intestines. Small quantities of whey 
and barley water, with the addition of the juice of an underdone chop, may 
be given at short intervals during both day and night. Improvement having 
taken place as regards the diarrhoea, milk in some form or other must be 
given. Milk modified so as to reduce the proteids to '5 or 75 per cent., 
with 2 per cent, fat and 5 per cent, sugar, may be given, or one of the forms 
of desiccated milk already referred to. The amount of proteids should be 
gradually increased, if they appear to be digested well. It may be worth 
trying milk which has been predigested by pancreatine. Every care must 
be taken that the feeding bottle is clean, and the food prepared with the 
most scrupulous care. Whenever the weather permits, the infant must be 
taken into the open air as much as possible. The medicines given must be 
selected according to the most prominent symptoms. If the stools are 
loose, contain much mucus and curd, and are foul or stinking, small doses 
of castor-oil emulsion or calomel should be given, to be followed by bismuth 
and small doses of opium. If the stools are dark brown or yellow and very 
liquid, astringents in the form of extract of logwood, catechu, or pomegranate 
will be of most service, especially if small doses of opium are given by the 
bowel. (F. 20, 32.) If the diarrhoea approach the dysenteric type, much 
mucus and blood being passed with straining and forcing down, irrigating 
the bowel with a warm decoction of starch and boric acid (20 to 30 oz.) or 
small enemata of starch and opium may be used with advantage. 

The treatment of chronic gastric catarrh in infants when it has become 
confirmed is very often extremely discouraging. In the milder forms of 



iio Diseases of the Digestive System 

vomiting the importance of modifying the milk so as to reduce the quantity 
of curd, or ofpeptonising the milk to gain the same end, must be insisted 
upon ; milk foods containing much fat are usually badly borne. It is also 
of much importance not to give food too frequently, but to give the stomach 
a complete rest for several hours. In severer cases in which milk or whey, 
in whatever form it is given, returns sour and curdled in a few minutes, 
other food must be substituted at least for a time. In such cases Mellin's 
Food, either made with water or weak veal broth (half a pound to the pint), 
may be given ; the bottle being discontinued and the infant fed with a 
spoon. Instead of veal broth, raw meat juice or ' liquid meat' may be used. 
After a few days, milk may be again tried, or small quantities of cream may 
be added to the Mellin's Food in lieu of the meat juice. In this acid con- 
dition of stomach small doses of sodii bicarb, and pepsine are often very 
useful. (F. 34, 35.) 

In older children careful dieting is of the utmost importance, and the 
first difficulty encountered will probably be that the child has been over- 
indulged and so spoilt by its parents that it is difficult to get it to take a 
carefully selected and restricted diet. In arranging a diet it must be borne 
in mind that the child should take only such quantities as the impaired state 
of the digestive juices can deal with, any excess being liable to undergo decom- 
position in the intestines, and give rise to flatulence and other troubles. It 
is also most important to give the stomach a complete rest during the 
intervals between meals ; sweet biscuits taken during the morning or a run 
on the kitchen at frequent intervals during the day are fruitful sources of 
chronic indigestion, and the plainest and most peremptory directions should 
be given to the parents by the medical attendant that nothing whatever . 
should be taken except at regular meals. If the child refuses or only half 
gets through its breakfast, this should by no means be supplemented by a 
second edition at the parents' table, or a tasty lunch to make up for the 
morning's deficiencies. It is wiser by far, if the breakfast is but half taken, 
to let the child wait till the next meal ; a little starvation can do no harm, at 
any rate much less than over-indulgence and the formation of bad habits. 
The importance of fresh air and change of scene in cases of habitual indi- 
gestion can hardly be over-estimated. The worst kind of exercise is a ' con- 
stitutional ' taken with the nurse or governess ; outdoor games of various 
kinds, gymnastics, riding, or driving, or some form of recreation which will 
occupy the mind and give an interest to the exercise, are far preferable to 
any dull routine. A change to the seaside, or some bracing elevated inland 
site where there is a keen cool air, will often work wonders in these cases. 
It must, however, be remembered that such cases are often worse, or there 
is no improvement, at first ; children when first removed to the seaside are 
apt to do too much and eat too much : they are over-tired and fretful at 
night, and attacks of dyspepsia or perhaps eczematous or other eruptions 
occur. A caution is often necessary to prevent this. 

It is wiser in most cases to lay down a complete diet chart for the gui- 
dance of the parents, though a certain latitude must necessarily be permitted 
on account of varying tastes. The following diet tables may be taken as 
samples, which can be modified according to circumstances: 



Chronic Intestinal Catarrh 1 1 1 

Diet for a child of 5 to 7 years, indigestion not severe : 

Breakfast, 8 A.M. — A breakfast cupful (8 oz.) of bread and milk, made 
from whole meal bread ; a teaspoonful of malt extract may be added ; 
this may be followed two or three times a week by the yolk of a lightly boiled 
egg on strips of toast, or a piece of toast and dripping or bacon fat. 

Dinner, 12 to I P.M. — A broiled mutton chop, finely mi?iced, or fresh white 
fish, with mashed potato, spinach, or French beans ; to be followed by 
ground rice pudding or a baked apple. Milk to drink. 

Tea, 4 to 5 P.M. — A cup of cocoa and milk, with toast or stale bread. 

Supper, 7 P.M. — A cup of beef tea or mutton broth. 

In the more severe and protracted cases it is well to avoid farinaceous 
food as much as possible, as recommended by Dr. Eustace Smith. 

Breakfast, 8 A.M. — Half to three-quarters of a pint of fresh milk, alkali- 
nised by twenty drops of the saccharated solution of lime ; a slice of toast 
with yolk of egg, or fresh fish. 

Dinner, 12-1 p.m. — A small mutton chop or boiled sole, a thin slice 
of stale bread, with half to a wineglassful of sherry or bitter beer, well 
diluted. 

Tea, 4-5 p.m. — Same as breakfast. 

Supper, 7 p.m. — A cup of beef tea. 

In some of these cases of chronic dyspepsia, especially where the stools 
are pale, the amount of milk which the child takes must be lessened in 
quantity — the milk given being much diluted with cocoa made with water, 
or peptonised milk may be given. 

In all cases of habitual indigestion it is of much importance to sponge 
every morning with cold or tepid water (6o°-jo°), keeping the child's feet in 
warm water during the process, if it is subject to cold feet or has a sluggish 
circulation. A shower bath is often of much service. After the morning's 
bath friction with as rough a towel as the child's skin can stand should be 
used. The child's dress should consist of woollen garments next to the skin, 
and every chance of getting cold should be avoided. 

The medicines which are of the greatest value in these cases are nitric 
acid in combination with helaline and pepsine (lT]xv to 1T[xxx of the liq.), 
or euonymin and pepsine may be given. Arsenic is often of much value, 
but requires to be given in increasing doses to bring out its full value. For 
a child of seven years, three-drop doses may be given, and gradually 
increased to six drops, or it may be given in small granules, which are 
readily taken by children, preferably an hour after food. At the same time 
it is well to order a saline purgative, which shall keep the bowels relaxed 
rather than loose. Alkalies with senna or rhubarb are often prescribed 
with much advantage. (F. 38, 39.) Later, when convalescence is established, 
acids and bitters should be given. (F. 36, 37, 40.) 

If the bowels keep confined, a small granule containing half a grain of 
aqueous extract of aloes may be taken at dinner time daily ; in many cases 
a grain will be required to keep the bowels well open. This may be sup- 
plemented, especially if the stools are pale, by an ounce or two of Hun- 
yadi water, to which an equal quantity of warm water has been added, to be 
taken two or three times a week before breakfast, or Rubinat or Friedrichs- 
hall water, half a wineglass to a wineglassful in warm water, or a teaspoonful 



I 12 



Diseases of the Digestive System 




of effervescing Carlsbad salts, may be taken before breakfast two or three 
times a week, and decreased or increased according to the state of the 
bowels. 

Dilatation of Stomach. — Dilatation of the stomach during infancy is 
commonly the result of a long-continued gastric catarrh ; in rare cases it is 
secondary to a congenital stenosis of the pylorus or duodenum, or upper 
part of the small intestine. In the minority of cases the dilatation takes 
place rapidly, as in acute gastric or gastro-intestinal catarrh, or in ' cholera 
infantum,' but it is far more frequently found in weakly infants or children 
who have suffered for months from chronic dyspepsia and who are probably 
anaemic and rickety. It is easy to understand that, if the digestive fluids 
are weak and insufficient to properly digest the food, the curd of milk and 
starches decompose in the stomach, and gases are given off in large quanti- 
ties. The constant distension of the stomach keeps the muscular walls on 
the stretch, the muscular fibres become thin and atrophic, and the distended 
condition tends to become permanent. The muscular mucous membrane, 

including the glandular 

elements, is wasted. The 

effect of a dilated stomach 

is to add to the dyspeptic 

,; ' £}M? troubles ; like a dilated 

\ wBfc^V* % anc * powerless bladder, its 

\k "* r'vj contents become stagnant 

and decompose ; it never 
thoroughly empties itself, 
but always contains much 
mucus and decomposing 
curd of milk. These 
dilated stomachs some- 
times reach an enormous 
size. Henschel records a 
stomach of an infant two weeks old with a capacity of 190 cc. (normal 
70 cc.) ; an infant of three months with a stomach of a capacity of 485 cc. 
(normal 150 cc.) ; another of four months, of 500 cc. (normal, 180 cc.) ; 
and another of ten months of 650 cc. (normal, 300 cc). The symptoms 
are not very definite, and we have on several occasions discovered post 
mortem a considerably dilated stomach, which we had not detected during 
life. There is chronic dyspepsia, discomfort after food, distension of the 
stomach with gases, coated tongue, and in some cases chronic vomiting. 
The diagnosis may be difficult ; in some cases the limits of the dilated 
stomach may be mapped out by percussion, but this can only be done 
if the colon and small intestines are not distended. If the colon is 
much distended, it will probably be impossible to distinguish between the 
tympanitic note produced by percussing the stomach and that produced by 
percussing the colon. A splashing sound may sometimes be produced by 
shaking the child, in cases of dilated stomach, if there is much fluid in the 
stomach. The prognosis is not necessarily bad, as there can be little doubt 
that under favourable conditions the stomach may recover itself. The 
treatment is that of chronic dyspepsia : washing out is especially useful. 




Fig. 15. — Stenosis of Pylorus, showing narrow channel, 
hypertrophy of muscular fibres, and hyperplasia of the 
mucous coat ; death at six weeks. (Life size.) (From a 
drawing by W. E. Fothergill.) 



Dilatation of the Stomach 



i i 



Dilatation of the stomach, sometimes extreme in degree, is present in 
congenital obstruction of the duodenum and ileum. (See p. 149.) 

Congenital Stenosis of the Pylorus. — In rare cases there is a congeni- 
tal stenosis of the pylorus with a secondary dilatation and hypertrophy of the 
walls of the stomach. We have seen several such cases. The infant, which 
is born healthy, begins to vomit at about the end of the first week ; the vomit- 
ing continues, large quantities are ' pumped up ' till the stomach is empty. 
The vomiting then ceases for perhaps 12 or 24 hours, and the vomiting 
comes on again. No bile is vomited, the stools are small and constipated. 
Wasting quickly takes place, and death from exhaustion occurs in 6 or 8 
weeks. In cases where the stenosis is slight, the symptoms are less marked, 
and life may be prolonged for 6 months or more. But little can be done in 
the way of treatment ; at the post-mortem the pylorus is found thickened, 
forming a tumour, which has in some cases been felt during life, the thick- 
ening being due to hypertrophy of the muscular layer, the mucous coat is 
also thickened. The pyloric channel is narrow, and the walls of the stomach 
hypertrophied. (See fig. 15.) 





Fig. 16. — Hour-glass constriction of stomach, from an infant of five months. The 
muscular walls of the narrowed part were much thicker than the walls of the rest of 
the stomach. (Natural size.) 

Malformations of the Stomach. — These are certainly uncommon, but 
a slight degeee of hour-glass constriction which had been unsuspected during 
life may at times be found at post-mortems. In a case of our own in which 
we made the section, but did not see the infant during life, there was a well- 
marked contraction in the central portion of the stomach. (See fig. 16.) 
There was a history of constant vomiting during life. In such a case it is 
very possible that there is no real malformation ; but it is difficult to say 
whether the narrowing is due simply to a spasmodic contraction of the normal 
muscular coat at this spot, or whether there was a true hypertrophy. 

Carcinoma of the Stomach. — New growths in the alimentary canal are 
exceedingly rare in early life. We have met with one case, but the new- 
growth was more duodenal than gastric. The case was shortly as follows : 

Oliver G. , aged 8 years, was admitted to hospital Sept. i, 1890. He was a thin boy, 
with distended abdomen and symptoms of cystitis. There had been no vomiting, pain, 
or diarrhoea. The abdominal distension was considerable : the coils of intestines could 
be distinctly seen through the abdominal walls. There was no tenderness, and no tumour 

I 



i 14 Diseases of the Digestive System 

could be felt. He was discharged February 21, 1891, somewhat improved, having made 
flesh during his stay. He was re-admitted April 23, 1891. The abdomen was distended 
and tender, and a tumour could be felt below the edge of the liver, to the right of, and 
about the same level as, the umbilicus. There were frequent attacks oi severe colicky 
pains. He gradually emaciated, and died May 15. The post-mortem showed that the 
transverse colon near the hepatic flexure, the duodenum and omentum, were matted 
together; the stomach was dilated, and its walls thickened. The pyloric opening just 
admitted the forefinger ; on the cardiac side of the pylorus were two small growths, the 
size of peas ; on the duodenal side there was an irregular cavity, the walls of the first part 
of the duodenum having been destroyed by anew growth ; lower down were some polypoid- 
looking growths; below these the mucous membrane was normal. Microscopical exami- 
nation showed the growth to be a columnar epithelioma. 

Ulcer of Stomach. — Tubercular ulcers of the stomach are rare in 
children ; we have seen only one example. When puberty is passed simple 
ulcers may occur. We have known severe haematemesis occur from tuber- 
cular ulcers in the jejunum. 

Intestinal Worms 

The worms which most commonly infest children are the thread worms, 
round worms, and tape worms, of which the former are the most common. 

Thread Worms (Oxyuris). — These troublesome pests inhabit the lower 
bowel, i.e. caecum and appendix, colon, sigmoid flexure, rectum, and the 
vagina; an unhealthy state of the mucous membrane with sluggish bowels ap- 




Oxytcris veriniczilaris, female. Highly magnified. 
(Quain's ' Dictionary of Medicine.') 

pearing to favour their development. To the naked eye they appear like short 
pieces of white thread : under a low power the females, which are the more 
numerous, are seen to taper at each end, and their uterine ducts will be seen 
to contain numerous oval-shaped ova, some of the latter containing embryos. 
These parasites gain entrance into the system by the ova being taken in the 
food, or perhaps more frequently by means of the ova adhering to the fingers 
of those already affected ; they are thus conveyed directly or indirectly to 
others. The extreme fertility of these worms makes it certain that any one 
who is affected with thread worms and is not of scrupulously cleanly habits 
will have ova adhering to the neighbourhood of the anus which may be 
transferred by the fingers to the individual's own mouth or to others. The 
symptoms are very uncertain, the diagnosis being usually made by the 
patient's friends detecting the parasites in the chamber vessel used by the 
child. The most common symptom to call attention to the presence of thread 
worms is the irritation and itching which they are apt to give rise to at the 
anus or entrance to the vagina. Girls will suffer from excessive discharge 
of mucus from the vagina, sometimes containing blood, from the presence of 
oxyurides in the vagina or the result of scratching. In many cases the 
presence of thread worms seems to give rise to no symptoms whatever. 
Weakly anaemic children with sluggish bowels are most often affected. The 



Intestinal Worms — Thread Worms 



115 




treatment consists in expelling" the worms, preventing their re-entrance, and 
in improving the health of the child so that it is less likely to provide a favour- 
able cultivation ground for these unwelcome guests. The first indication is 
best fulfilled by a sharp purge to expel or else to drive them into the lower 
bowel, to be followed by enemata to destroy those present in the colon and 
rectum, and wash away any excess of mucus present ; a grain to two grains of 
calomel, in combination with two or three grains of resin of scammony, may 
be given to children of three to eight years of age overnight ; and the following 
evening, if the bowels have been well acted upon, an enema of infusion of 
quassia as large as can be given should be used. It will be well to repeat the 
enemata every other eveningfor a week or two. Great care should be exercised 
to see that the child is washed about the genitals with soap and water after 
each stool to prevent re-infection. Injections should be used repeatedly to 
free the vagina from any of these worms, if there is any 
vaginitis or irritation. Weak carbolic acid lotions will 
answer very well, and some dilute red oxide of mercury 
ointment (1-3) may be smeared at the entrance to the 
vagina. The general health of the child must also be 
thought of and a careful diet prescribed, excess of 
sweets and starches being avoided. If constipation 
exist, Rubinat or Hunyadi water should be given every 
other morning before breakfast, in sufficient quantity 
to produce a soft stool without purging : sulphate of 
iron, gr. §— j, with spirits of chloroform and orang~e 
flower water, twice a day, is often very useful. Cod- 
liver oil in selected cases is of great service. 

Naphthalin is an effective anthelmintic for thread worms, but it is dis- 
agreeable to take. It may be given as suggested by Schmitz in doses of two 
to five grains four times a day till eight doses have been taken ; repeat in 
a week's time. If necessary the dosing must be repeated after a week's 
interval. Enemata of corrosive sublimate (1-1,000) after the bowels have 
been freely moved is an effectual local application. 

Round Worms (Ascaris lumbricoides). — The common round worm 
measures from four to twelve inches in length, the females being somewhat 
longer than the males ; they are reddish white and have more or less resem- 
blance to common earth worms. They mostly inhabit the small intestines, 
but are apt to wander into the stomach, large intestines, or even into the 
gall bladder. Several may exist in the intestine at the same time, in ex- 
ceptional instances many hundreds may be present. They gain entrance 
into the system by means of their ova, which are swallowed with the food ; 
the shells surrounding the ova are dissolved by the gastric juice, setting free 
the embryos. The symptoms produced by the presence of round worms 
cannot be certainly distinguished from those of dyspepsia or intestinal catarrh, 
with which the ascarides are so commonly associated. The passage of a 
round worm per rectum is often the first thing to call attention to the subject ; 
on the other hand, mothers often dogmatically assert that their child has 
worms because he ' picks his nose ' and his ' food appears to do him no good.' 
The latter symptoms, it is needless to say, are not diagnostic of the presence 
of worms, but of an unhealthy state of the alimentary canal. The presence 



Fig. 18.— Eggs of Oxy- 
nris vermicularis en- 
closing embryos x 450 
diam. (Quahrs ; Dic- 
tionary of Medicine.') 



1 1 6 Diseases of the Digestive System 

of one or two round worms rarely produces any symptom per se, unless they 
pass into the stomach or bile duct. In larger numbers they may give rise to 
colicky pains, especially at night: diarrhoea, vomiting, and symptoms of ob- 
struction of the bowels have occasionally resulted. In rare instances worms 
have found their way into the peritoneal cavity and been discharged with 
the contents of an abscess through the abdominal wall. The treatment is not 
as difficult as the diagnosis. Santonin combined with calomel or castor oil 
should be given, and is almost certainly successful after a dose or two has 
been given. Santonin, gr. j-iij, calomel, gr. £-j, may be given overnight, and 
some fluid magnesia or other saline next morning before breakfast. Or the 
santonin dissolved in two or three teaspoonfuls of castor oil may be given 
before breakfast. The santonin may be repeated once or twice, but not 
oftener, until the physiological effects (if any have been produced) have 
passed off. If the santonin cause vomiting, smaller doses should be tried or 
compound scammony powder substituted. 

Tape Worms are as common in children as in adults, both the TcBnia 
soli inn and 71 mediocanellata being found. Infants and young children less 
often act as hosts for tapeworms, but they have been found in infants under 
a year old. Attention is first called to the fact by the passage of the joints 
or proglottides in the stools. Older children will often complain of pain in 
the epigastrium, and peculiar movements are felt inside ; they are apt also 
to lose flesh and suffer from various dyspeptic symptoms. The difficulty 
of dislodging the greater part of the creature is not great, but the head is not 
so easily expelled, especially that of the T<z?iia solium. The success of the 
treatment by means of the administration of male fern depends upon the in- 
testine containing as little food as possible. A dose of castor oil should be 
given overnight sufficiently large to act freely before morning ; twenty to 
thirty drops of etherial extract of male fern (freshly prepared) should be given 
in half an ounce of mucilage and water before breakfast ; breakfast should 
consist of some light refreshment such as beef tea : at noon another dose of 
castor oil should be given, which will act in the course of the day, bringing 
away the intruder. Careful search should be made for the head, bearing in 
mind that the joints are likely to break about an inch from the head, that the 
latter is about the size of a large pin's head, and the thickness of the worm 
itself near the head is only that of a stout thread. 

If, after careful search by a competent observer, the head is not discovered 
in the stools, after a few days the treatment may be repeated, but it is not 
wise to continue to repeat the male fern, as toxic symptoms are apt to arise. 
Decoction of pomegranate root may be substituted if it is necessary to con- 
tinue the treatment. 

Ascites 

Fluid is sometimes present in the peritoneal cavity of the child without 
dropsy elsewhere, and it may be difficult to decide as to its cause. The 
diagnosis of ascites when it forms part of a general dropsy, as in cardiac 
disease or renal disease, is easy and does not call for special comment. 

An ascites which is primary in a child is usually the result of some lesion of 
the peritoneum, as chronic peritonitis, or the result of portal obstruction such 
as mediastinitis, cirrhosis, or perihepatitis. The detection of a large or 



Ascites 117 

moderate quantity of fluid in the peritoneal cavity is not difficult, the per- 
cussion note being dull in the flanks, while the region round the umbilicus is 
tympanitic in consequence of the distended intestines floating upwards when 
the patient is lying on his back ; change of position on to the side will float 
the intestines to the highest point, and the flank which is uppermost will now 
be resonant. While change of the patient's position will thus cause the fluid 
to gravitate to the lowest point if it is free in the peritoneal cavity, it 
must be borne in mind that in chronic peritonitis there may be a matting 
together of the intestines which prevents them from floating upwards, and 
consequently there may be no alteration in the percussion note after change 
of position. The amount of dulness to percussion may vary from day to day 
according to the varying distension of the intestines. In ascites the super- 
ficial veins of the abdomen are usually enlarged, the skin becomes shiny 
and stretched if the fluid is excessive, and often the umbilicus is protruded 
and pouched out, containing fluid which can be pressed back into the 
abdominal cavity. The detection of a small quantity of fluid in the abdo- 
men is difficult, especially when the intestines are much distended with 
gas and the large bowel is loaded with faeces, the latter giving a more 
or less dull percussion note in the flanks. Fluctuation may be felt 
by passing the finger into the rectum ; fluid may thus be detected in 
the pelvis. A careful observer is hardly likely to mistake simple dis- 
tension of the intestines with gas for ascites ; the thrill imparted to the 
contained fluid by gently tapping the flank is absent in the flatulent dis- 
tension, and on percussion the abdomen is universally tympanitic. The 
diagnosis of the cause of the ascites is often difficult, as a large accumulation 
of fluid may be due to chronic peritonitis and closely resembles an ascites due 
to portal obstruction. Chronic peritonitis may be quite unaccompanied by 
pain or tenderness from first to last, and the fluid may be excessive. Any 
matting or induration of the omentum or intestines to be felt through the 
abdominal walls, or a slight evening rise in the temperature or signs of tuber- 
culosis elsewhere (as in the testis), or chronic diarrhoea, would be in favour 
of chronic peritoneal tuberculosis. A normal temperature, the ascitic fluid 
freely movable, the general health good, slight jaundice or bile pigment in 
the urine, would be in favour of portal obstruction, as cirrhosis or medias- 
tinitis. If the fluid is localised by the presence of adhesions, and does 
not occupy the whole peritoneal cavity, it is probably due to tuberculosis. 
The possibility of hydatids of the peritoneum must be borne in mind. An 
enlargement of the spleen with ascites suggests cirrhosis of the liver. 



i i 8 Diseases of the Digestive System 



CHAPTER VII 

DISEASES OF THE DIGESTIVE SYSTEM — (continued) 

Acute Peritonitis 

ACUTE general peritonitis is not an uncommon disease during infancy and 
childhood. It occurs as a primary disease, but more often the inflammation 
spreads from some organ or structure with which the peritoneum comes into 
relation. It sometimes follows a blow or some injury to the peritoneum. 
The foetus also suffers from peritonitis perhaps more subacute than acute, 
and the adhesions which are left surrounding and matting the intestines are 
apt to interfere with the growth and development of the gut, and lead to 
stenosis or obstruction by narrowing the bowel or tying it up in coils. 
Acute peritonitis occurs in the newly born, secondary to arteritis or 
septicaemia ; but such cases are rare in private practice. Apart from these 
cases, peritonitis is not common in infants and young children. Dr. West 
mentions a case of idiopathic peritonitis occurring in an infant of seven 
months, which proved fatal in six days ; the attack was sudden, accom- 
panied by vomiting and abdominal distension ; after death, lymph and 
serous fluid were found in the abdominal cavity. We have known it in 
infants and young children to spread from a suppurating mesenteric gland. 
Acute peritonitis occurs in older children by no means infrequently, super- 
vening, without known cause, in the midst of apparent health ; in other 
cases there is a history of a chill, or a blow upon the abdomen, and at the 
ftost-mo7'tem there is nothing to indicate where the inflammation commenced. 
Not infrequently the peritonitis is the result of some lesion in the caecum, 
vermiform appendix, or mesenteric glands. It sometimes occurs in tuber- 
cular subjects : thus a phthisical boy of nine years old was suddenly seized 
with pain in the abdomen and vomiting, and died in ten days : at the 
ftost-mo7'tem an acute general peritonitis was present, and also adhesions 
from old peritonitis and some calcified mesenteric glands. Acute peritonitis 
may be caused by the spread of inflammation from other parts, as from the 
pleura, an empyema bursting through the diaphragm, from the pericardium, 
ulcers in the stomach, duodenum, ileum, or caecum, or from intussusception. 
It may occur in the course of typhoid fever from perforation of the 
intestine and extravasation of faeces. It is rare in the course of scarlet 
fever, but it is not uncommon in the, last stages of the succeeding nephritis, 
when uraemic phenomena have set in ; it is then mostly of a purulent 
character. We have seen peritonitis post mortem, which was associated 



Acute Peritonitis I 19 

with an acute enteritis, and it seems probable that, in some cases, an 
apparently idiopathic peritonitis is set up by a bacterial infection from the 
intestines. 

Symptoms and Course. — The symptoms of acute peritonitis in the infant 
and child are by no means always as characteristic as they are in the adult, 
and cases will sometimes occur where extensive peritonitis is found at the 
Post-mortem which was not suspected during life, especially when it super- 
venes in the course of some other disease. 

The attack usually begins with vomiting, sometimes diarrhoea, and great 
pain and tenderness in the abdomen referred to the region of the umbilicus : 
the amount of tenderness on pressure varies even in cases where no opium 
has been given, and where the patient is under the influence of this drug pain 
may be entirely absent. Constipation after the onset is a marked feature 
when the attack is established, no faeces and often no wind passing" by the 
bowel ; the vomiting is constant, the distension of the bowels very great, so 
that the coils of distended small intestines may be seen through the abdo- 
minal walls, and the case may readily be assumed to be obstruction of the 
bowels from some mechanical cause. Though no complete obstruction 
exists, yet the coils of intestine are seen post mortem to make sharp turns 
on one another, ' kinks ' being formed, which, with the layers of lymph on 
their surface, must seriously impede the passage of their contents. The 
paralysis of the muscular coat of the bowel, by diminishing or arresting the 
normal peristaltic movements, further prevents the onward movement of the 
intestinal contents. The vomiting is mostly constant as long as food is 
given ; undigested food, bile, and sour-smelling intestinal contents may be 
brought up, but the vomited matters are seldom faecal as they are in hernia 
or intussusception. There is usually moderate fever, the temperature being 
101 to 102 F., but a normal or subnormal temperature may persist through- 
out the case, and distension is not always present. The pulse is nearly 
always considerably quickened. 

In the later stages the abdominal distension is often extreme, the coils of 
distended intestine may be readily discernible through the walls of the abdo- 
men, the face becomes pinched and blue, the pulse quick and thready, and 
the patient dies collapsed, often suddenly at the last. While this is the all 
but universal ending of a case of general peritonitis, when the symptoms have 
fully declared themselves, cases undoubtedly occur in which the diagnosis of 
peritonitis is made, on account of the distension and pain in the abdomen, 
which gradually improve under treatment, and finally recover. There is 
reason to suppose that cases of acute peritonitis will occasionally get well, 
even when the attack has been a general one. In other cases the symptoms 
of a local suppuration, hectic, local tenderness, and swelling, succeed to those 
of a general peritonitis. In such cases, presumably, there may have been 
a local peritonitis from the first. 

The following cases will illustrate some of the above remarks : 

Acute Suppurative Peritonitis.— John C. , aged 7 years. The family history was good. 
He had been a strong boy up to the time of his fatal illness. No cause could be assigned 
for his sickness. Four days before admission to hospital he complained of pain in the 
' stomach ; ' there was vomiting and constipation. On admission to hospital on the fifth 
day of his illness, the face wore an anxious expression, as if he was in pain ; the abdomen 



120 Diseases of the Digestive System 

was distended and tense, and tympanitic and tender to the least touch ; his legs were 

drawn up ; he constantly vomited dark, sour-smelling, almost faecal stuff. The urine, 
drawn off by a catheter, contained albumen. All food and drink by the mouth were 
stopped, and he was given ten-minim doses of tinct. opii every second hour till three doses 
had been given. He passed a restless night, yet was drowsy from the effects of the 
opium. He gradually sank, dying on the evening of the sixth day of his illness. At the 
post-mortem, on opening the abdomen, a few ounces of offensive pus escaped ; the surface 
of the intestines was injected ; the bowels were matted together with lymph ; there was no 
strangulation. The caecum and vermiform appendix were normal ; there were patches 
of intense congestion on the mucous surface of the ileum, and a sharply cut ulcer (not per- 
forating), half an inch in diameter, some two feet above the caecum. No certain cause 
for the acute peritonitis was found, unless it be assumed — which is indeed not improbable 
— that an enteritis existed in the first instance, and that the peritonitis was secondary. 

Acute Peritonitis. — Boy, 13 years, said to be delicate, but never ailed anything. He 
played with his brothers on Wednesday afternoon , tumbling about on the floor — no definite 
history of a blow. Thursday he did not eat his breakfast, and said he felt sick ; vomited 
several times during the day, and was thought to be upset from a disordered stomach. 
Friday morning vomited, and in much pain ; bowels acted slightly ; not much distension ; 
child died same evening, 6 P.M. Post-mortem, Monday, July 29, 1889. — Some decom- 
position ; omentum normal ; surface of small intestines intensely injected, most marked 
below umbilicus ; some lymph, not excessive quantity ; bloody serum between intestines, 
a few ounces in pelvis. Vermiform appendix : external surface injected ; no evidence of 
past inflammation. Slitting up of intestines showed them to be'normal, except the lips of 
the ileo-caecal valve, which were injected ; the appendix seemed thickened and cedematous, 
and contained some mucus only. Lungs were normal ; heart also normal ; the blood 
dark and fluid, and there were small extravasations of blood on the surface of the heart. 
In this case the boy died in two days from acute peritonitis. No cause could be assigned, 
unless it resulted from a blow when playing with his brothers the day before he was taken 
ill. There was no bruising of the abdominal wall. 

In the following case the symptoms closely resembled acute obstruction 
of the bowels from strangulation : 

Acute General Peritonitis. — John C, aged 9 years, was healthy up to February 9, 
when he was injured by a blow in the abdomen ; but the injury does not seem to have 
been very severe. He complained of pain in the belly, and vomited the same evening. 
He continued to vomit five or six times a day till his admission to hospital (under 
Dr. Hutton) on the fifth day of his illness. He had passed nothing per rectum except a 
small stool after an enema, and it was supposed he was suffering from an intussusception. 
On admission his face was flushed, the eyes sunken ; the abdomen was tightly distended, 
the coils of intestines being plainly seen. He complained of paroxysms of pain in the 
abdomen. He vomited faecal matter shortly after admission ; there was pain on deep pal- 
pation in the right iliac fossa, but no marked tenderness. Full doses of opium were given. 
The next day (the sixth of his illness) it was thought advisable to make an exploratory 
opening into the abdomen (which was done by Mr. Wright) ; the intestines were deeply 
coloured, and matted together with lymph ; no constricting band or invagination was de- 
tected ; the wound was closed and a drainage tube inserted. The boy gradually sank, and 
died suddenly the next day. At the post-mortem a general acute peritonitis was found ; no 
cause for it was made out after a careful search. 

In the light of the post-7/tortem examination, it would seem that saline 
purgatives or purgative doses of calomel would have been worth trying in 
the above cases. 

In the following case the peritonitis was secondary, occurring in the 
course of scarlatinal nephritis : 

Acute Nephritis : Peritonitis. — Sarah W., aged eight years, was attacked with scarlet 
fever, the initial symptoms being vomiting, high fever, and rash. She was admitted to 



Acute Peritonitis 12 1 

hospital on the third day. The tonsils were sloughy ; there was much glandular enlarge- 
ment and high fever. The temperature varied from ioo° to 101 '6° F. till the twelfth day, 
when it reached 102 6° F. , and a trace of albumen appeared in the urine. On the thir- 
teenth day the temperature was 104 F. , and only two hundred and fifty cubic centimetres 
of urine were passed. From the fourteenth to the sixteenth day the urine passed was only 
from seventy to one hundred cubic centimetres daily ; urine contained fibrinous and epi- 
thelial casts. Eighteenth day, vomiting, temperature 103 F. ; only seventy cubic centi- 
metres of urine. Nineteenth day, no urine passed ; severe abdominal pain, respirations 
shallow and thoracic, abdomen distended and tense. Twentieth day, temperature 98 to 
99 F. , patient collapsed. Twenty-first day, death. At the autopsy a general sero-purulent 
peritonitis was found ; pleurisy of left lung ; acute glomerular nephritis. 

In the following case the cause of the peritonitis was doubtful, but there 
is no doubt it was very extensive, and it is a good illustration of the value of 
operation even in extreme cases of purulent peritonitis. This boy was dusky 
and so ill that we hesitated to operate at all. 

Acute Purulent Peritonitis : Operation, Recovery. — Fred A., aged ia|. Six weeks 
before admission was kicked by a horse in the right side of the abdomen. He was 
apparently not much hurt, and was allowed by his doctor to get up on the following day. 
Five weeks after the accident, on May 27, 1894, he had slight abdominal pain, supposed 
to be due to eating cucumber. Vomiting and pain soon followed, and tenderness in the 
right iliac fossa a day or two later. The pain spread upwards, vomiting increased, and 
extreme tenderness appeared in the left hypochondrium, with collapse. He was admitted 
on June 4. At that time he looked very ill ; anxious face ; pulse small ; abdomen full, 
moves very little with respiration ; legs moved freely ; abdominal walls rigid, tenderness 
most marked on left side ; nothing specially to be felt on right side. A few hours later, 
face dusky and blue ; rectal examination revealed greater resistance on the left side than 
on the right. The abdomen was opened in the middle line below the umbilicus, and a 
large quantity of faecal pus escaped. The abscess filled up the left iliac fossa, and 
appeared circumscribed, but there was resistance in the right side also. He gradually 
improved ; the quantity of pus escaping from the tube and its fcetor lessened, and though 
for some time there was tenderness in the right iliac region, he steadily got well, and was 
heard of in good health four or five months later. 

Diagnosis. — A pleurisy of the base of one or other of the lungs is often 
mistaken for peritonitis, as the sharp stabbing pain is apt to be referred to the 
abdomen where the intercostal nerves terminate. In some cases, especially 
if the pleurisy involve the diaphragm, the similarity to peritonitis may be 
great, and it is common to find that hot fomentations or mustard poultices 
have been placed upon the abdomen by the friends under the idea that there is 
peritonitis. Where pleurisy exists there is no real tenderness of the abdomen 
on pressure, and the physical signs of pleurisy or pleuro-pneumonia will be 
detected in the chest. An attack of colic is not often likely to be mistaken 
for peritonitis ; in the former there is pain and distension of the abdomen, but 
no tenderness or elevated temperature. An intussusception may be mistaken 
for peritonitis ; but the attack of pain is more sudden in the former, and 
there is not often much tenderness; the detection of an elongated tumour 
would usually decide the diagnosis ; both an intussusception and also 
peritonitis maybe present. Acute peritonitis is apt to be mistaken for acute 
obstruction of the bowels, such as results from the constriction of a knuckle 
of bowel by a band. The distension of the intestines with flatus, the vomit- 
ing of sour-smelling intestinal contents, as well as complete obstruction to 



122 Diseases of the Digestive System 

the passage of wind, may be present in both ; there may be little tender- 
ness, and but slight or no fever. The diagnosis may be very difficult or 
impossible, though the history of the case, the absence of faecal vomiting, 
and the less complete obstruction to the passage of both flatus and fajces in 
the case of peritonitis, will usually help the decision. It is hardly necessary 
to add that it is only in some cases of acute peritonitis that the difficulty exists, 
as usually the pain, tenderness, and distension of the intestines are diagnostic 
of peritonitis. 

Morbid Anatomy. — The tendency to pus formation, which all inflamma- 
tions in children exhibit, is noticeable in peritonitis, as in acute cases the 
fluid found in the peritoneum is thick and turbid, or it may rank as pure pus. 
The amount of lymph and fluid varies in different cases ; pus or turbid 
serum will often be found in meshes of lymph between the coils of intestines, 
a larger collection being present in the pelvis. In all cases of apparent 
idiopathic peritonitis, a careful search should be made for a local starting 
point : the caecum, mesenteric, and retro-peritoneal glands being carefully 
examined. 

Prognosis. — This is always grave ; the more acute the symptoms, the 
more rapidly the fatal result occurs. The prognosis in any case mostly 
depends on the diagnosis, for, if acute general peritonitis is present, a fatal 
result is almost certain. 

Perityphlitis. Appendicular Peritonitis.— Instead of a general peri- 
tonitis taking place, a local inflammatory action may be set up, which results 
in simple inflammatory induration going on in many cases to the formation 
of an abscess, or a general peritonitis ma)" supervene. The commonest 
local peritonitis is a typhlo-peritonitis or perityphlitis as it is generally 
called. The caecum is especially apt to be the seat of irritation, a peculiarity 
which it doubtless owes to its being a cul-de-sac, in which foreign bodies or 
impacted faeces are apt to lodge, and give rise to various forms of trouble. 
Pins, fish bones, cherry stones, are apt to lodge in the caecum, and occasionally 
gravitate into the caecal appendix, and though the latter is not normally 
traversed by the intestinal contents as they pass downwards, concretions are 
likely to form from the deposition of faecal particles, inspissated mucus, 
phosphates of lime, and other salts. As a result, ulceration of the caecum or 
appendix is very apt to take place, and a perforation to be followed by a 
local or general peritonitis. In the majority of cases it is now well recognised 
that in most cases the mischief begins in an inflammation of the appendix 
due either to retained secretion or to the presence of some solid matter 
which may be formed in the appendix, or enter it from the bowel ; occasion- 
ally there is tubercular disease of the follicles of the appendix, but this 
would give rise to more chronic symptoms. Rheumatic and other forms of 
appendicitis are described, but the name is of doubtful value. The appendix 
from its richness in adenoid tissue may be looked upon as the tonsil of the 
large intestine, and like the faucial tonsils may become inflamed as a result 
of direct infection with poisonous matters. The symptoms presented by 
perityphlitis in the child resemble those present in the adult. The attack 
may begin with diarrhoea and perhaps vomiting, with more or less obscure 
pain and tenderness in the abdomen, and feverishness. It is often extremely 
difficult to localise the pain and tenderness in a small child, and it may be 



Perityphlitis — Appendicular Peritonitis 123 

quite impossible at first to refer the tenderness to any one spot, especially 
as the abdominal muscles are apt to be rigidly contracted, and the child 
cries directly it is touched. The state of the bowels varies ; sometimes they 
are relaxed, at other times obstinately constipated. In the course of a few 
days, during which time the pyrexia continues, if a satisfactory examination 
can be made, more or less resistance may be detected by palpation in the 
iliac or lumbar region, and a dulness on gentle percussion, though this may 
be masked by the distension of the small intestines. The patient may now, 
especially if he has been judiciously treated, gradually improve, and all pain 
and tenderness disappear in the course of a week or two. On the other hand, 
the tenderness may increase, a distinct hardness and induration may be felt 
in the right iliac region, the right leg is drawn up, and the child cries with 
pain if it is moved. The subsequent course of the attack is uncertain : there 
may be a gradual subsidence of all the symptoms, or if the abscess is not 
opened, the hectic fever may continue, the child gradually emaciate, while 
the pus which has been formed is making its way to the surface, and the 
abscess may point in the iliac region, may discharge into the bowel, or, in 
rare cases, into the bladder or vagina. Faeces may be found in the pus dis- 
charging from the iliac abscess, and a faecal fistula result, or all the signs of 
general peritonitis, abdominal distension, extreme tenderness, and collapse, 
may come on. 

The diagnosis of perityphlitis is often by no means easy, and yet of 
much importance, inasmuch as a mistake in diagnosis may readily cost a 
life. In the early stages, the diseases most likely to be confounded with it, 
especially in small children, are coprostasis or accumulation of hardened 
faeces in the caecum, and invagination of the intestines ; in a later stage, 
when the patient is seen for the first time after an abscess has formed, there 
maybe uncertainty as to the source of the pus. Children who have just begun 
to run alone, and are able to make frequent excursions into the kitchen, or 
who are fed on all sorts of indigestible food, are especially liable to suffer 
from an accumulation of hardened feces in the caecum, which may set up 
more or less irritation, and give rise to symptoms exceedingly like those of 
a perityphlitis. There is distension of the abdomen, colicky pains, vomiting, 
slight feverishness, constipation, or, on the other hand, diarrhoea ; and it 
must be borne in mind that looseness of the bowels is quite compatible with 
a loaded caecum or large intestine. It may be possible to detect a faecal 
tumour in the right lumbar region. The diagnosis in a fretful spoilt child 
may be exceedingly difficult, but the symptoms of impacted faeces in the 
caecum will be rather those of colic, the pain coming on spasmodically, with 
no pain or tenderness in the intervals ; while in perityphlitis the pain will 
be constant, and the tenderness on deep pressure unmistakable. In any 
given case it is far better to err on the safe side, and to mistake colic for 
typhlo-peritonitis, than to fall into the more serious error of overtreating a 
child suffering from a local peritonitis with purgatives and enemas. An 
ileo-caecal invagination with its symptoms of sudden obstruction of the 
bowel is probably not very likely to be mistaken for perityphlitis ; the 
sudden attack in an infant in perfect health, the colicky pains, the straining, 
and passage of blood and mucus, and the presence of a painless tumour, 
would in most cases prevent a mistaken diagnosis. To make a diagnosis, 



I 24 Diseases of the Digestive System 

an examination under chloroform may be necessary with the finger in the 

rectum. 

The value of rectal examination was well shown in a patient of Dr. 
Denholm's, in whom, with signs of peritonitis, no evidence at all conclusive 
could be found of the locality of the mischief till an examination of the 
rectum was made while the child was under chloroform. A mass was then 
felt filling up the pelvis on the right side, and a diagnosis of appendicular 
peritonitis, with the appendix hanging over the brim of the true pelvis, was 
arrived at. An incision as for ligature of the external iliac artery allowed 
the peritoneum to be turned forward, and the abscess was with some 
difficulty reached, and opened without soiling the general cavity of the 
peritoneum, which must have been inevitably done if the abscess had been 
sought by the usual route. The appendix was felt lying in the abscess 
cavity. The child did perfectly well. 

Peritoneal Abscess. Intestinal Fistula. — Apart from the suppuration 
which is liable to take place as the result of a typhlo-peritonitis, other aoscesses 
are liable to occur in the abdomen, due in the majority of cases to tubercular 
disease in the mesenteric, retro-peritoneal, or rectal glands. Local abscesses 
may also occur as the result of a blow or following a perforation of the intestine 
in typhoid fever or tubercular ulceration. As an instance of a glandular 
abscess in the abdomen the following case may be taken as an example : 

Abdominal Abscess : Discharge of Pus at Umbilicus. — A girl of seven years of age was 
admitted to hospital, having suffered for thirteen days with pain in the abdomen, fever, 
and vomiting. On admission there was some dullness below the umbilicus and great 
tenderness ; the temperature varied from ioo° to 102° The day after the umbilicus 
became prominent and the skin red ; it gave way and pure pus was discharged. The 
wound continued to discharge for some time — on one occasion a cheesy mass was removed 
from the sinus, followed by a fresh discharge of pus ; the sinus finally closed on the forty- 
eighth day. At the end of ten weeks the girl was fat and strong ; there was some indura- 
tion, but no pain or tenderness below the umbilicus. On one occasion there was some 
pus in a stool. 

Abdominal Abscess: Operation. — A girl of 12 years was seized with vomiting, fever, 
and abdominal tenderness; sordes formed on the teeth, the tongue was brown, there was 
extreme distension of the abdomen ; the bowels did not act, and no flatus was passed. 
On the eighth day there was a crisis, the temperature fell to normal and the pulse from 
120 to 80. At the same time a slight prominence was noted just below and to right of 
umbilicus ; this was cut down upon and 2 oz. of faecal pus escaped. The recovery was 
uninterrupted. 

Tubercular Abscess. — In an infant, seen with Dr. Xoble, of Kendal, it was noticed a week 
or two after birth that the abdomen was more rounded and distended than usual. When 
five weeks old the abdomen was intensely distended, shiny, with enlarged veins on the 
surface, and with redness and protrusion of the umbilicus ; the abdomen was resonant all 
over, and nothing could be felt on palpation. A few days later the skin at the umbilicus 
gave way, and pus discharged freely. The infant a few days after died in convulsions. 
A large abscess cavity was found at the autopsy, and caseous mesenteric glands. Apparently 
this was a case of congenital tuberculosis. 

In other cases, with somewhat similar but more chronic symptoms, there 
has been evidence that an abscess had formed, probably in a mesenteric 
gland, and had opened into the bowel, pus being discharged with diarrhceal 
stools. Other cases occur which are by no means so satisfactory in their 
terminations, being in many instances associated with a chronic tubercular 



Peritoneal Abscess — Intestinal Fistula 125 

peritonitis or mesenteric disease. There are symptoms of abdominal 
trouble, attacks of vomiting and diarrhoea, hectic fever and wasting, an 
induration and at length an inflammatory blush around the umbilicus ; the 
latter becomes perforated and pus discharges. Frequently, sooner or later, 
the discharge becomes faecal from the presence of intestinal contents, a fistu- 
lous opening having become established. In the majority of such cases the 
abscess apparently originates in a mesenteric gland, an abscess cavity is 
formed which is surrounded by coils of small intestine matted together, and 
the abscess opens both at the umbilicus and into the bowel in some part of 
its course ; but as such cases are mostly chronic, opportunities for post- 
mortem examinations are not frequent, and when an opportunity presents 
itself there is so much matting of parts that it is difficult to make out the 
origin of the abscess. 

The following case illustrates this difficulty : 

Abdominal Abscess : Fcecal Fistula. — A girl of four years of age was in hospital, June 
1879, with obscure abdominal symptoms, hectic and wasting ; in the following December 
she was admitted with a sinus at the umbilicus, discharging pus and intestinal contents, 
an abscess having broken ten weeks before. The fistulous opening continued to discharge 
pus and liquid yellow gaseous faeces till her death in October 1880. At the post-mortem 
the liver and spleen were lardaceous. The umbilical sinus was connected w ; th an abscess 
cavity containing one or two ounces of pus and faeces, and surrounded on all sides bv 
intestines matted together ; this cavity communicated with the ileum a foot and a half 
above the caecum by two openings large enough to admit a little finger. On the peritoneal 
surface of the small intestines were cretaceous nodules, apparently the remains of a past 
tubercular peritonitis. In the ileum were many cicatrices and calcaieous remains of old 
ulcers and cheesy solitary glands. 

In this case the perforation of tubercular ulcers or the suppuration of 
mesenteric glands had been the cause of the abscess and fistulous openings. 
In several cases coming under notice the fistulous openings have closed up 
permanently, one after discharging for seven months, and in some others 
the fistulous opening has closed, but the patient died of general tuberculosis. 

Treatme?it. — The treatment of peritonitis will naturally depend upon its 
cause, and unfortunately we are constantly in doubt about this, or indeed if 
peritonitis exists at all, especially in the early stages of some abdominal case. 
In any case of peritonitis or doubtful case, we must feed with the greatest 
care, allowing only small quantities of readily absorbed forms of nutriment, 
such as Brand's essence or bovril, and only small quantities of fluid of 
any sort. These may be given iced. If the vomiting is severe and continu- 
ous, all fluid must be withheld by the mouth and rectal feeding adopted. 
Hot fomentations applied to the abdomen relieve pain and comfort the 
patient. Some prefer to apply an ice-bag, but it is not as comforting as 
warmth and heat. Opium given with a free hand has been our sheet-anchor 
hitherto in the treatment of peritonitis, but of late years there has been a 
considerable revulsion of feeling, especially on the part of abdominal surgeons. 
There can be no doubt of its value in relieving pain and checking the intense 
griping which often occurs, but on the other hand it masks the symptoms 
and makes diagnosis more difficult, helps to paralyse the intestinal waHs and 
so lock up the intestinal contents and favour the formation of toxines in the 
stagnant fluids in the bowel. In suitable cases there can be no doubt that 



126 Diseases of the Digestive System 

saline purgatives are of the greatest value in clearing out the bowels and 
getting rid of flatus. There can hardly be a doubt that in past times we 
have been too much afraid of purgatives, and have erred too much on the 
side of keeping the bowels at rest and thus locking up their contents. In 
any case of obstruction of the bowels from a constricting band or an imagi- 
nation, it is clear that purgatives can do nothing but harm, but on the other 
hand, in a case of general peritonitis secondary to enteritis or intestinal infec- 
tion, they afford the best chance for the patient. In appendicular peritonitis 
we have in the past been too much dominated by the ' cherry-stone ; in the 
appendix and the supposed necessity of keeping the parts absolutely at rest 
to use anything but opium or its derivatives. In any case seen e.arly in which 
we can exclude invagination or strangulation of the bowel, we should cer- 
tainly give a purgative, preference being given to salines or calomel to secure 
a free evacuation of the intestinal contents. An enema containing sweet oil 
and turpentine should be given to clear away the contents of the large 
bowel ; it is seldom that an efficient enema is given by the patient's friends, 
and it is better for the medical man to see for himself that it is done tho- 
roughly and efficiently. Nepenthe or morphia should be given to relieve pain, 
and is best given in association with belladonna. The amount to be given 
and further treatment of the case must depend upon the decision come to as 
regards operative interference. 

Since acute purulent peritonitis is practically certainly fatal if it becomes 
generalised, it is of the utmost importance to provide an outlet for a localised 
abscess rather than allow it to go on and rupture into the general peritoneal 
cavity. Hence, as soon as it is clear that a local form of inflammation is not 
subsiding under medical treatment, the safest course is to carefully cut down 
upon and let out the pus. In perityphlic abscess ('appendicular perito- 
nitis'), when with fever there is local pain, tenderness and induration and 
drawing up of the leg, an incision should be made just internal to the anterior 
superior spine of the ilium and the successive muscular layers divided until 
the neighbourhood of the abscess is made clear either by the sense of fluc- 
tuation or by the cedematous condition of the tissues : a director is then 
thrust in the direction of the suspected cavity, and if pus appears the opening- 
is enlarged with dressing forceps and the cavity drained and treated on 
ordinary principles (antiseptics being used unless the pus is foul). There is 
little danger in such an operation ; even if no abscess is met with and the 
peritoneal cavity is opened, no ill result is likely to follow, while the danger 
of rupture of an abscess into the general peritoneal cavity is very great. 
Local peritoneal abscess elsewhere is much more uncommon, though it may 
be met with on the left side (perisigmoid abscess), and this can be made out 
at times by rectal examination. The treatment is that of the perityphlitic 
condition. It is of little importance in such cases to make out whether the 
abscess is really a local peritonitis or a collection of matter in the cellular 
tissue outside the peritoneum, since, if peritoneal, it is usually completely 
shut off by adhesions from the general cavity, and there is no fear of pus 
flowing from the wound into the peritoneum. Local abscesses elsewhere 
must be treated on similar principles. Should a general purulent peritonitis 
already exist, the question of treatment is more uncertain and the prospect 
far less hopeful ; there is, however, little dpubt that the right course is to 



Peritoneal Abscess — Intestinal Fistula 127 

open the abdomen, wash it out with some unirritating antiseptic, such as 
boracic lotion, and drain the peritoneum. Should there be general faecal ex- 
travasation from perforation of the caecal appendix, or from a typhoid ulcer, 
the case must be looked upon as well-nigh desperate ; the attempt, however, 
may be made to expose the perforation, suture the intestine, and in the case 
of the appendix remove it and close the end. Cases of iliac abscess of 
uncertain origin are not uncommon, and operation is almost always success- 
ful, and though it may be said that these are a different class altogether from 
the local peritonitis group, it is difficult to distinguish between the two, and 
there is certainly a risk of perforation into the peritoneum. In appendicular 
abscess nothing more should be done than simple incision and drainage ; 
no attempt should be made to remove the appendix or look for a cause of the 
suppuration except that the finger maybe gently passed into the abscess and 
any foreign body removed. We have several times found a faecal concre- 
tion lying loose in one of these cavities. The greatest care must be taken 
not to break down the wall of adhesion round the abscess. The opening of 
a local appendicular abscess is in our experience. almost always a successful 
operation, but it is of course far otherwise if the suppuration has been from 
the first, or has been allowed to become general ; in such a case, too, a full 
search must be made for the source of the trouble, and an attempt made to 
remove it, whether by ligature and excision of a perforated appendix, or such 
other means as the particular case may require. 

In cases of recurrent 'appendicular peritonitis' removal of the appendix 
is undoubtedly the proper course to pursue, since life is in constant danger 
as long as the source of the mischief remains. Recurrent appendicitis, so 
common in young adult life, is not very frequently seen in children ; in them 
the more delicate tissues seem to suppurate more readily, and abscess is the 
rule. We cannot emphasise too strongly the desirability of early operation 
in these cases. If with a high temperature a child has a distinct induration 
or sense of resistance in the right iliac region, the sooner the swelling is 
explored the better. We have never regretted operating, and never failed to 
find pus in these cases, even where its presence seemed doubtful. We feel 
sure from observation that in many instances in which it has been supposed 
that ' resolution : took place there has really been an abscess which discharged 
into the bowel. 

Iliac Abscess. — The occurrence of iliac abscess, right or left, is fre- 
quent in children, and the various causes of such mischief should be borne in 
mind ; the principal ones, some of which have been already mentioned, are 
caries of the spine, tubercular disease of the mesenteric glands— in this case 
the abscess is more often umbilical — disease of the hip, innominate bones, or 
sacro-iliac joint, perinephritic abscess, rare in children, and the still rarer 
cases of hydatid cysts. Empyemata, superficial abscesses and abscesses 
the result of injury, ' simple psoitis,' &c. are to be thought of in addition to 
those already described as resulting from irritation of the caecum or appendix. 
But besides all these, it is common to find iliac abscesses the cause of which 
remains obscure, and we are satisfied that in many of these cases the suppu- 
ration is simply due to inflammation of lumbar, iliac, or pelvic lymphatic 
glands, just as cervical abscesses occur from irritation of the glands of the 
neck. The source of irritation is often doubtful, but is sometimes due to the 



128 Diseases of the Digestive System 

presence of worms or other irritating matters in the bowels ; sometimes to ex- 
tension from the more superficial lymph glands. The diagnosis can usually 
be made by careful exclusion and by the history ; rectal examination is often 
of much value, by enabling the extent and position of the abscess to be 
made out, as well as sometimes by revealing a source of irritation. These 
abscesses should be opened antiseptically and drained in the usual way : it 
will often be found that they extend for long distances upwards or down- 
wards into the pelvis. The limb on the affected side should be steadied by 
a splint or by extension. The prognosis is good, provided no permanent 
source of suppuration be present. Almost every case that we have seen 
has recovered, and we believe this is largely due to early opening of the 
abscesses. 1 

Chronic Peritonitis. — Chronic peritonitis is a comparatively common 
affection during childhood, and in the vast majority of cases is tubercular. 
A few cases of chronic non-tubercular peritonitis in which the diagnosis has 
been confirmed by a post-mortem have been recorded, notably one by Henoch 
which ran a course of six weeks ; at the post-mortem cloudy fluid and orga- 
nising lymph were found in the peritoneal cavity. This case seems to have 
originated in a blow. Cases frequently occur in practice of chronic 
peritonitis with ascites, in which there is no evidence of tubercle in any organ, 
and which completely recover ; this, however, is no bar to the acceptance of 
the belief that such are tubercular, as there is ample post-mortem evidence 
to show that tubercles and lymph on the surface of the peritoneum may be- 
come cretaceous or be converted into fibrous tissue. Two forms of chronic 
tubercular peritonitis are met with in practice, in which for the most part a 
well-marked clinical difference exists, one distinguished by the large amount 
of ascitic fluid and in which probably ascites is the only symptom present, 
and the chronic cicatrising form in which there is induration and thicken- 
ing" of the great omentum and a matting together of all the abdominal organs 
with little or perhaps no fluid. The same tubercular process is going on in 
both cases, but produces in one a large amount of effusion, in the other less 
or perhaps no fluid, but the effusion of lymph and its gradual organisation 
and cicatrisation. 

Ascitic Form. — Chronic peritonitis is by far the most common cause of 
ascites, or rather dropsy commencing in the peritoneal cavity during child- 
hood, while, as well known, some form of portal obstruction is the commonest 
cause in adults. Ascites due to chronic peritonitis is not common during 
the first year of life ; not that it does not occur, but the infant dies before the 
chronic stage is reached. It is not uncommon during the second year of 
life, and occurs with some frequency up to and beyond puberty. There is 
generally a history of pain in the abdomen of a more or less obscure kind 
which has been regarded as due to indigestion, probably also both feverish - 
ness and diarrhoea, and then the belly begins to swell. In some cases the 
enlargement of the abdomen is the first symptom which leads the friends to 
think anything is wrong with the child. On examination a rounded and 
distended abdomen is found, there is dulness and fluctuation to be felt in the 
flanks if the patient is lying on his back ; while there is a more or less ex- 

1 For details of some of these cases we may refer to a paper in the Arch, of Pediatrics, 
vol. i. 1884, and to the Children s Hospital Abstracts ; also Lancet, February 1891. 



Tubercular Peritonitis 129 

tended region of resonance around the umbilicus where the distended small 
intestines are buoyed up to the surface. The fluid may, however, be localised 
by adhesions. The abdomen is often greatly distended, the skin tense and 
shining, the abdominal veins enlarged and tortuous, and in young children 
the skin at the umbilicus is protruded, and contains fluid which can be pressed 
back into the abdomen. There is usually complete absence of pain and ten- 
derness, the disease is frequently feverless during the greater part of its 
course, and the patient looks rather as if he were suffering from ascites due 
to some obstruction in the portal system. The course of the disease is 
essentially chronic, and recovery frequently takes place if the tubercular 
disease remains local. 

Thus in one case a girl, aged 13 years, who was in hospital for some 
five months, and from whom eight to nine pints of ascitic fluid were re- 
moved through one of Southey's canulas, completely recovered, and was 
four years after a strong girl, supporting her mother and family by her work. 
In many similar cases we have seen recovery take place ; one suffered from 
a tubercular testis which discharged through the scrotum and healed. On 
the other hand, such children are apt to be carried off by a tubercular menin- 
gitis, or the mesenteric glands become cheesy, or a tuberculosis of the lungs 
takes place. In any case it will, of course, be necessary to carefully examine 
the lungs, and a long-continued hectic and wasting would suggest a more 
extended area of tuberculosis. In cases which end in recovery there is 
probably a matting together of the intestines, and frequently more or less 
induration may be felt about the great omentum or caecum. In cases which 
are of long standing it occasionally happens that a perihepatitis with more 
or less cirrhosis of the liver takes place. This was the case in a boy of 3^ 
years who was admitted to hospital under the care of Dr. Hutton, with ascites, 
cedema of the feet and ankles, jaundice and enlarged liver ; at theflost-mortem 
the liver weighed 15 oz., the capsule was thickened and the surface was 
irregular and granular ; on section there was a great excess of fibrous tissue, 
old and recent peritonitis and tuberculosis of the lungs. 

Cicatrising Form. — In many cases of tubercular peritonitis there is little 
or no ascites from first to last, but lymph is effused on the surface of the 
peritoneal covering of various organs, and if the patient live long enough, 
fibrous adhesions are formed. On the post-)iwrtem table, local or general 
peritonitis is frequently found in children dying of tuberculosis ; thus, out of 
105 post-mortems of tubercular children made during the four years 1882-85, 
there was peritonitis in 38, though in comparatively few of these was the 
peritonitis an early and important lesion. While this form of peritonitis is 
mostly chronic, yet some cases run a more active and subacute course. The 
early symptoms are pain in the abdomen, usually referred to the umbilicus, 
often attacks of sickness and diarrhoea, hectic, and the presence of induration 
or irregular-shaped masses felt through the abdominal walls. The amount 
of tenderness on pressure differs greatly ; it is most marked in the acuter 
cases, and absent in the chronic ones. But in cases wasted and exhausted 
by acute disease, even a purulent peritonitis may be present without 
any pain ox tenderness. The state of the abdomen varies, it is sometimes 
distended with gas, at other times more or less retracted; often no distinct 
tumour can be felt, but on very gentle percussion a distinct loss of resonance, 

K 



130 Diseases of the Digestive System 

or a muffled resonance, may be detected over the umbilical region in conse- 
quence of the thickening and induration of the great omentum, or a resist- 
ance may be felt on palpation, or hard irregular tumours can be detected, 
the result of matting together of the omentum or intestines. Hectic fever is 
mostly present, the temperature rising to 102 or 103 at night and falling to 
normal in the morning, and more or less general wasting of the body ensues ; 
but the amount of fever and wasting present will depend upon the extent to 
which the mesenteric glands and thoracic viscera are affected. Diarrhoea is 
not usually a marked symptom unless tubercular ulceration has taken place. 
The subsequent course of these cases differs much ; in the minority, after- 
several months of hectic, improvement slowly sets in and the patient improves, 
for a time at least appearing fairly well. In the majority the fever continues, 
the wasting becomes more apparent, diarrhoea, and perhaps cough, come on, 
and the child sinks. In others, the lungs remain free to the end, but mesen- 
teric disease ensues, ulceration of the bowels takes place, perhaps local 
abdominal abscesses form, and the liver, spleen, and kidneys become 
lardaceous. In only four of the thirty-eight cases of fatal tubercular 
peritonitis mentioned were the lungs and mediastinal glands found entirely 
free from tubercle. 

Prognosis. — The course of chronic tubercular peritonitis is usually long, 
unless some intercurrent disease, as tubercular meningitis, supervenes. 
Children may be under observation for many months, with either ascites or 
induration of the omentum, with more or less hectic, and with no evidence 
of any active disease of the lungs, and finally to all appearance completely 
recover. On the other hand, the onset of diarrhoea, hectic, progressive 
emaciation, and cough, with evidence of lung mischief, points to the exist- 
ance of more or less generalised tuberculosis, which necessarily shortens 
the duration of the illness. Albuminuria, as pointing to lardaceous disease, 
would be of bad omen. 

Diagnosis . — When a child is brought with an ascites which has made 
its appearance gradually without pain or fever, it is perhaps not unnatural to 
attribute the collections of fluid in the abdomen to obstructed portal circu- 
lation. In an adult the commonest cause of ascites is cirrhosis of the liver 
in a child by far the most frequent cause is chronic tubercular peritonitis. 
In a given case it is perhaps quite impossible to make a certain diagnosis, inas- 
much as for a while the ascites may be the only symptom present ; there may 
be a complete absence of pain or tenderness, and the most careful palpation 
fail to detect any induration of the omentum. The bowels may float up and 
cause a resonant note on percussion at the umbilicus when the patient is on 
his back, the resonance shifting to the flank which is uppermost when he lies 
on his side. It may be impossible to feel the edge of the liver, or map it out 
by percussion. In other cases, however, there will be less difficulty, for there 
is hectic fever, or diarrhoea, or abdominal pain and tenderness, or after para- 
centesis lumps or masses of induration may be felt. A family history of 
tuberculosis would naturally favour the view of tubercular peritonitis ; and 
occasionally the presence of a cheesy deposit in a testis will decide the 
diagnosis. The fact that the fluid is encysted is in favour of tuberculosis. 

Morbid Anatomy. — Fluid varying in quantity will be found in a few 
cases ; it may be clear or cloudy serum or pus, in which latter case it is 



Tubercular Peritonitis 131 

usually localised : it is not uncommon, on separating the intestines, to find 
small local collections of pus. Tubercles and lymph are usually present on 
the great omentum and mesentery, matting the intestines together, also 
between the liver and diaphragm and around the spleen ; where there is no 
large collection of fluid, the adhesions are frequently very extensive ; the in- 
testines and stomach may be adherent to the abdominal wall, so that on 
opening the abdomen the intestines are cut into. The intestines, mesentery, 
great omentum, liver, and spleen may be so matted together, partly by lymph, 
partly by fibroid adhesions, that it may be impossible to separate them. 
The intestines may be so adherent and bound down as to form bends and 
kinks that it is impossible to unravel. Cheesy mesenteric glands and tuber- 
cular ulcers will very likely be present. 

Treatme7it. — Any pain and tenderness in the abdomen in a child with 
tubercular tendencies should excite apprehension and never be neglected. 
Rest in bed must be enjoined, and a diet consisting of beef tea and milk 
should be given. The pain may be relieved by applications of belladonna 
and glycerine covered with cotton wool, or by fomentations. The bowels 
ought to be relieved by enemata and laxatives rather than purgatives. In 
the chronic stages, when the abdomen contains fluid or there is evidence of 
thickened and indurated omentum or cheesy masses, mercurial applications 
are of service. An ointment of yellow oxide of mercury (20 grains to the 
oz.), with an equal quantity of ung. belladonna?, may be applied, with cotton 
wool to cover it. Lin. hydrarg. may be used, but salivation is likely to 
follow if continued for too long a time. Tonics and cod-liver oil emulsion 
should be given. Chronic purulent peritonitis, whether tubercular or not, 
should be treated by incision and drainage, if the child's health is failing ; 
and there is good evidence to show that not only may temporary relief be 
thus given, but long lasting, if not permanent, recovery may take place as 
the result of incision. Even where the fluid is not purulent in obstinate 
cases drainage is of service ; it appears to cause adhesions and thus to 
prevent the re-collection of fluid, while at the same time cicatrisation takes 
place. We have little doubt that, in all cases of tubercular peritonitis 
in which there is any considerable collection of fluid, whether purulent or 
not, the abdomen should be opened and drained as soon as it is evident that 
in spite of treatment extending over some months no improvement is taking 
place. We have successfully employed this method, and are impressed with 
its value. 

Acute Obstruction of the Bowels. — Children occasionally suffer from 
acute obstruction caused by twists in the bowel, constricting bands, impac- 
tion of foreign bodies, and internal hernia ; by far the most frequent cause 
is, however, an intussusception. 

Intussusception 

The commonest cause of obstruction in infants is the presence of an 
invagination of the bowel. Many reasons have been given for this somewhat 
frequent accident. There is no doubt that one cause is to be found in the 
great reflex irritability of the muscular coat of the infant's bowel ; vigorous 
peristalsis is easily set up, and moreover, the intestinal walls being thinner 
during infancy than in later life, an invagination of one portion of the gut 

k 2 



132 Diseases of the Digestive System 

into a lower portion more readily takes place. This is seen in the post-mortem 
invaginations so often found : the act of dying seems to stimulate the 
peristalsis of the bowels, and it is no uncommon thing to find on \\\o. post- 
mortem table many invaginations in the ileum an inch or two in length. In 
some cases an accident, such as falling out of bed, or some rapid movement 
up and down in the parent's or nurse's arms, has preceded symptoms of an 
intussusception, and it is possible that a sudden movement might cause a 
toneless piece of gut to become invaginated. It must also not be forgotten 
that the infant's intestines, especially the caecum and colon, are more 
movable than those of an adult, having a wider mesentery, and consequently 
one piece of bowel is more easily dragged into another portion. 

The exciting cause of intussusception is occasionally found to be a 
polypus, more often an inflammatory thickening of the caecum, or some 
hardened nodule of faecal matter which adheres to the wall of the gut, and 

sets up local peristalsis. We have met 
with a case, related below, in which 
a local tubercular peritonitis causing 
thickening of the bowel was the im- 
mediate cause of the invagination. 
Sometimes tubercular caseating glands 
are found in the mesentery, which has 
been dragged into an intussusception. 
This occurs in children of over eighteen 
months or two years of age, rather than 
in infants. It is quite probable that 
such a gland pressing into the wall of 
the gut may be the starting-point of 
the invagination. 

Fig. 19.— Ileo-caecal intussusception, a, Ileum With rpcrnrd to the fremipnrv of 

(the intussusceptum) ; b, cut edge of window Wltn regard to tne trequency of 

in colon made to show the middle layer ; intussusceptions at different ages, it has 
c, colon (the Intussuscipiens). , ,. —... , , 

been stated by Pilz that, out of 293 cases, 
153 were in their first year, and of these 98 were from four to six months of 
age. According to Leichenstern, out of 122 cases, 73 were under a year old 
and 49 from one to five years of age. It is certainly the common experience 
that the majority of cases occur in infants under -a year, and that from four 
to six months of age is a very common time. 

In at least three-fourths of the cases in infants the invagination is ileo- 
caecal, in the minority of cases it is ileum into ileum or colon into colon. In 
the ileo-caecal variety the ileum enters the caecum, not through the ileo-caecal 
valve, but the caecal valves are pushed before it, so that the valves themselves 
occupy the lowest part, and as it travels downwards, more and more of the 
ileum enters, dragging its mesentery along with it and forming the inner tube 
while the middle layer is formed by the inverted caecum and colon, the 
colon also forming the outer layer. The layers of an intussusception there- 
fore consist of (1) an outer layer of intestine into which the invagination 
takes place, the peritoneal coat being external and the mucous membrane 
internal ; (2) a middle layer continuous with the outer layer at its upper end 
but turned inside out so that the mucous membrane is external and the 
peritoneum internal ; (3) an internal layer formed by the intestine entering 




Intussusception 133 

the outer layer with its mesentery and vessels, and this becoming nipped 
as it travels downwards forms the obstruction. In consequence of the 
mesentery becoming dragged in, the included intestine does not lie in 
the centre of the containing gut, but is more or less tilted to one side. 
As a result of the invagination, the inner and middle layers become 
congested and cedematous and of a dark-red colour ; blood is extravasated 
from the congested mucous membrane and is passed per rectum. In some 
cases, lymph is thrown out by the serous surfaces and a local or general 
peritonitis takes place. In a few cases, more particularly in the ileum into 
ileum variety, sloughing may take place and the invaginated bowel be 
separated and passed per rectum, while faeces may be extravasated or 
recovery take place by a process of cicatrisation. The extent to which life 
is threatened depends very largely upon the tightness with which the bowel 
is nipped and the circulation of blood obstructed, and this appears to vary 
to a considerable extent, so that death may ensue in a few hours with the 
symptoms of collapse, or, especially in older children, where the bowel 
is only partially obstructed and the circulation of blood through it but 
slightly interfered with, the course may be chronic, going on for weeks or 
even months. 

Symptoms. — An infant of a few months who may very probably have 
suffered for a few days from symptoms of bowel irritation, suddenly begins 
to kick and scream as if in violent pain which nothing appears to relieve. It 
soon begins to vomit continuously, and strain as if it wanted to pass a stool, 
but nothing escapes but a little blood and mucus. In the intervals between 
the attacks of vomiting and colic, the infant may be tolerably quiet, but it is 
usually restless and moaning as if in pain. On examination of the abdomen 
with the warm hand it is usually found more or less soft and flaccid, and on 
careful palpation in the course of the transverse colon, an inch or so above 
the umbilicus and towards the left hypochondriac region, an elongated 
tumour may be felt, which is movable, and, as a rule, not acutely tender. 
There may be also a feeling of want of resistance in the right lumbar 
region from the absence of the csecum and ascending colon. In very 
fat infants it may be impossible to detect such a tumour. We must not 
however, forget that if an early examination be made no tumour may be felt, 
inasmuch as the invaginated portion of ileum may only have passed two or 
three inches into the caecum and lie too deeply to be felt. If it travels as far 
as the splenic flexure of the colon, it is tolerably certain to be felt. In some 
cases, as in one related below, no tumour was felt after forty-eight hours. 
The rectum should be next carefully explored with the finger, and the presence 
of a tumour there, which is pressed down when the child strains, while the 
withdrawn finger is covered with blood, would establish the diagnosis. The 
position of the tumour necessarily varies according to the length of the 
included gut ; but inasmuch as the colon is nearest the abdominal wall 
where it crosses the upper part of the umbilical region, if this part is involved, 
as it usually is, the tumour will be most readily felt here. The temperature 
is mostly normal or subnormal, unless there is peritonitis, when it may be 
raised a degree or two. The tumour is usually not acutely tender, but if 
the case be an acute one, or, in other words, if the included gut be tightly 
jammed and its vessels strangulated, the child may scream on its being 



1 34 Diseases of the Digestive System 

pressed. If the case continues unrelieved, the vomiting, straining, and 
distress continue, the child wears an anxious, pinched expression, with 
sunken eyes, and dies with the symptoms of collapse. The period at which 
death takes place varies ; in infants it may be within twenty-four hours, 
more often from the third to the fifth day. 

While the above description applies to the majority of cases, it must be 
borne in mind that the symptoms are at times far less well marked, so that 
the presence of an intussusception may be overlooked ; there may be perhaps 
vomiting, colicky pains, and mucoid stools, the infant dying in convulsions. On 
the other hand, it is possible that an invagination may occur, and fortunately 
right itself before it becomes tightly impacted. 

We have already remarked that an intussusception is by far more common 
in infants under six months or a year than it is in older children, and when it 
occurs in the latter, the symptoms in the early stages especially may be ill 
defined and consequently the diagnosis is difficult. There will be vomiting 
and severe colic with constipation, and in many cases no tumour can be felt, 
and there may be an entire absence of mucus or blood per rectum. In other 
cases the course is more subacute or chronic, there being no actual strangula- 
tion of bowel, at first at least, and the obstruction to the passage of faeces not 
being complete. In some of these cases there is some tubercular lesion, 
either old or recent, present in the abdomen, which has in some way or other 
contributed to the commencement of the invagination. (See Chronic 
Obstruction of Bowels.) 

The ileum into ileum variety is very uncommon in our experience in 
children. The symptoms produced will resemble those of a strangulated 
hernia with faecal vomiting and severe colic, and there may be, but not neces- 
sarily, mucus and blood passed by stool. 

The following case illustrates some of the difficulties of diagnosis, inasmuch 
as no blood or mucus was passed by the bowel and no tumour could be felt. 

Intussusception, Gangrene, Peritonitis. — A girl of 2 years (seen with Dr. A. Hopkinson) 
was knocked over by a perambulator, falling somewhat heavily on her side. Four days 
afterwards, during which period her bowels had acted normally, she was seized with acute 
vomiting and colic. She cried out from time to time, placing her hand on her abdomen, 
saying, ' Pain, mother, pain.' An enema was given without result. On the second day of 
the illness the vomiting and pain continued, the temperature was 99-6, the tongue was 
clean, the abdomen was not distended or tender. On the third day some chloroform was 
given, and a careful examination made of the abdomen, but no tumour could be detected. 
Fourth day. The abdomen was distended and tympanitic with some dulness in the left 
groin ; the pulse rapid and feeble, the eyes sunken, the vomiting, especially after food or 
fluid, continued, and also the paroxysms of pain. Death occurred on the fifth day. No 
stools or flatus were passed during the illness, no blood or mucus, and no tumour was felt. 
Post-mortem. Early stage of a general peritonitis, most marked on the right side. The 
large bowel was empty except the caecum, the latter forming a tumour nearly three inches 
in length, the ileum having become impacted into it for about that distance. No amount 
of force sufficed to reduce it. On incision of the caecum, the included ileum was found to 
be gangrenous. The appendix was long but otherwise normal. The mesentery contained 
some tubercular glands. (We are much indebted to Dr. A. Hopkinson for his notes of 
the case. ) 

The diagnosis in this case was exceedingly difficult. The girl had eaten 
some indigestible food a day or two before, more or less of which had 



In tussusception 



135 



returned in her vomit, and it was at first naturally assumed that the improper 
food was the cause of the sickness and colic. Apparently the lower two or 
three inches of the ileum passed through the ileo-caecal valves and quickly 
became tightly jammed. 

In the following case there was an old tubercular peritonitis and caseous 



Intussusception: Partial Obstruction. — Kathleen P., aged 5 years, was admitted into 
the Children's Hospital, September 27, 1895. The girl had enjoyed good health up to three 

/- 




Fig. 20. — Intussusceptum 
removed by operation. 
The invagination was 
ileo-caecal. (From, a 
drawing by Dr. W. E. 
Fothergill.) 




Fig. 21. — Longitudinal section of incLtssusceptum, 
fig. 20. The dotted lines show continuation of 
layers of intestine ; the inner being small intes- 
tine, the outer the encasing colon ; in di m, mu- 
cous membrane of intestine ; ^ j 5, peritoneal 
coat ; g. caseous mesenteric gland dragged in. 
(From a drawing by Dr. W. E. Fothergill.) 



months before admission, but latterly had been getting thinner, and at times suffered from 
abdominal pains and vomiting. It was, however, only during the last three weeks that 
she had been attended by a doctor, the abdominal pain being very severe, the vomiting 
persisting and the stools being sometimes simply loose, at other times consisting of pure 
blood or blood and mucus. The vomit was never faecal, but was sour-smelling and 
greenish in colour. The attacks of abdominal pain had been exceedingly severe, so that 
she rolled about in bed in agony. When admitted she was in a semi-collapsed state, but in 
much pain, twisting and writhing about in bed. The abdomen was somewhat distended : 
the coils of the intestines could be distinctly seen through the abdominal walls. The ab- 
domen was slightly tender to the touch, and an elongated tumour could be felt in the left 



136 Diseases of the Digestive System 

iliac fossa. This tumour was movable and could be rolled about under the fingers, and 
could be traced upwards totheedge of the ribs, where it was gradually lost The finger in 
the rectum detected a .soft cylindrical mass, high up with a definite ' os, 1 into which the finger 
could be introduced. Then was blood and mucus present in the rectum. It was abun- 
dantly clear that the only treatment was to open the abdomen, and if possible reduce the 
invagination. Accordingly the abdomen was opened in the left linea semilunaris, and the 
intussusception readily exposed. It was quite irreducible, so a longitudinal incision was 
made in the intussuscipiens and the intussusceptum excised ; the ends were united by an 
Allingham's bone bobbin and Lembert's sutures, but the child died in a few hours. It 
would have been better in this case to have strictly followed Barker's method, since after 
excision of the inner portion the ends separated and some faecal contamination occurred. 
(See figs. 20 and 21.) 

Morbid Anatomy. — On making a post-mortem examination, care must 
be taken to distinguish between an intussusception which has taken place 
during life and given rise to the symptoms noted, andan intussusception 
which is post mortem and caused by the irregular yet vigorous peristalsis 
of the bowels which may take place during the act of dying or after death. 
In the latter case the invagination involves the ileum, or at any rate the 
small gut, and there are often several of them. They are rarely more than 
an inch or two in length, are readily pulled out by gentle traction, and while 
a ring of congestion may be seen near the seat of constriction, or where the 
gut has been doubled on itself, there is no oedema or marked congestion or 
effused lymph. A post-mortem invagination does not completely occlude 
the passage of the gut. In the examination in a case of the ileo-caecal 
variety which has become strangulated, an elongated mass, dark red in 
colour, is seen lying in the course of the transverse colon continuous with it 
at its lower end, while the ileum with its mesentery is seen to enter at its 
upper end ; the ascending colon and caecum will have disappeared. In 
most cases the contained gut cannot be withdrawn without tearing, as it has 
become rotten from gangrene. Its passage will, in an acuce case, be com- 
pletely occluded, partly on account of the cedematous and congested two 
inner layers, partly by reason of the tilting on one side of the inner gut 
through the dragging in of its mesentery. Lymph may be found effused 
between the two peritoneal surfaces, gluing them together, and there may be 
evidence of a more general peritonitis. 

In chronic cases less congestion is seen, the bowel probably is not entirely 
obstructed, and the bowel above is generally hypertrophied and its mucous 
membrane in a condition of ulceration. We have already noted that some- 
times chronic inflammatory thickening is found in the caecum, and tubercular 
lesions of the peritoneum and glands. 

Diagnosis. — The diagnosis in an acute case in an infant is not likely to 
give rise to difficulty, inasmuch as the sudden attack of vomiting, with pain, 
straining, and the passage of blood and mucus from the bowel, and the dis- 
covery of an elongated tumour through the abdominal wall or per rectum, 
make the case tolerably clear. We may be more in doubt if with the above 
symptoms no tumour can be felt ; but we must bear in mind that a short 
ileo-caecal invagination may be present and lie too deeply in the right lumbar 
region to be felt. But the question of the presence of an intussusception 
sometimes arises in infants who are suffering from symptoms cf obstruction 
to the bowels of an uncertain origin, possibly with a certain amount of 



Intussusception 137 

thickening or resistance in the right iliac fossa, which may be due to the 
impaction of faeces in the caecum or to an invagination. In all such cases, as 
long as any doubt exists purgatives should be avoided, and small doses of 
opium given to allay the pain and straining. Purgatives have been shown 
by D'Arcy Power to have a peculiarly fatal effect in intussusception even 
when operation has been subsequently resorted to. If there is pain on deep 
pressure, it is better to avoid enemata, trusting rather to narcotics. In older 
children the error may be made of mistaking an ileo-colitis for an invagination 
of the bowel and vice versa (see ILEO-COLITIS), or obstruction of the bowels 
from other causes may be taken for intussusception. Complex forms of 
invagination are sometimes found ; thus Golding Bird has recorded a case in 
which an ordinary intussusception downwards was enveloped in a second 
retrograde invagination, and another in which an upward invagination took 
place into a persistent Meckel's diverticulum. Appendicular intussusception is 
alluded to later. 

Treatment. — The treatment which is to be adopted must necessarily 
vary according to the acuteness of the case and the time the symptoms have 
lasted, for if the bowel has passed into a gangrenous condition it is obvious 
that only harm can be done by treatment which might have been of the 
greatest service in an earlier stage. The questions to ask oneself before com- 
mencing treatment are, what is the state of the invagination ? is the gut 
tightly jammed ? is it gangrenous ? Unfortunately these questions are very 
difficult to answer, inasmuch as in some cases the inner layer of bowel 
becomes tightly impacted from the first, and no amount of force applied 
by distending the bowel per rectum will replace it, while in other cases suc- 
cess has attended inflation of the lower bowel with air several days or even 
a week after the onset of symptoms. Thus in a child 1 aged 7 months, under 
the care of Dr. J. S. Bury, injections of oil and afterwards of air were employed 
fourteen hours from the commencement, but failed to reduce the invagina- 
tion, the infant dying twelve hours later, within twenty-six hours of the onset ; 
at the post-mortem ' reduction was quite impossible without tearing the gut ; ' 
there was some lymph effused locally. In this case, by the end of twenty- 
four hours, the bowel was tightly strangulated, and neither by injections nor 
abdominal section could reduction have been effected. Such a case is no 
doubt exceptional, and it would probably have ended fatally under any cir- 
cumstances unless mechanical replacement could have been undertaken, or 
laparotomy performed within a very short time of the seizure. By the time 
the invaginated portion of the bowel has travelled along the colon as far as the 
rectum, the collapse produced, especially in a smallinfant, is very great, and 
the difficulties in the way of replacement are necessarily much greater than 
if only a few inches of bowel are involved. But cases appear to differ very 
much in the amount of oedema and congestion taking place in the nipped 
bowel, and consequently in the difficulty of replacement. While some cases, 
such as the one just referred to, are acute and irreducible almost from the 
first, others are reported in which the intussusception was reducible some days 
after the onset of symptoms ; in one case, reported by Dr. W. B. Cheadle, 2 
in a boy aged 5^ years, the invagination was successfully reduced by massage 
and the injection of air on the seventh day from the onset. In another case, 

1 Medical Times, Feb. 19, 1881. 2 La?icet, Oct. 23, 1886. 



138 Diseases of the Digestive System 

reported by F. H. Elliott, 1 in an infant of 8 months, attempts at intervals to 
reduce the invagination were at first only partially successful, but finally 
succeeded. 

As soon, then, as the existence of acute intussusception has been ascer- 
tained, it becomes necessary to decide what method of treatment should be 
adopted. 

Recoveries after spontaneous reduction and after sloughing have been 
recorded, but they are so rare that waiting for a natural cure means practically 
abandoning the child to almost certain death. Even if recovery by sloughing 
takes place, the risk of subsequent stricture has to be considered. It is then 
clear that some attempt at reduction should be made, and we have the fol- 
lowing plans at our disposal for this purpose. (1) Inversion of the child, 
combined with external taxis or succussion. The child is held up by the legs 
with the head downwards, and an attempt made to draw the contents of the 
abdomen to the upper part of the abdominal cavity by kneading and stroking 
with the hands through the abdominal wall, or by sudden shaking movements 
of the child an attempt is made to dislodge the intussusception. It is clear 
that this plan can only be expected to succeed when the intussusception is 
small in extent and recent in formation ; it is in such cases worth a trial, 
since it is unattended with danger. Chloroform should be given during the 
manipulations. 

(2) Distension of the bowel with fluid or air in the hope of pushing back 
the invagination. 2 If fluid injections are employed an enema tube fitted with 
an anal shield should be passed into the rectum, and warm water or oil 
allowed to flow into the bowel from a vessel raised above the level of the 
patient's body. The amount thus injected must vary with the age of the 
child and the position of the intussusception ; from one to two pints is about 
the usual quantity, and a fall of not more than three feet is required. 

Inflation by air is best managed by passing the nozzle of an ordinary 
pair of bellows, fitted with the pipe, into the rectum, and blowing air in till 
the tumour is felt to give way, or it is not safe to distend any further. In 
both these methods the abdomen should be carefully watched, and a hand 
kept on the intussusception tumour to feel for any change in its size or posi- 
tion. 

The following cases illustrate the success of these methods of treatment : 

Intussusception ; Injection of Air ; Recovery. — A fine healthy infant, 6 months old, 
was suddenly seized, on the evening of January 2 with griping pains and tenesmus. It 
had been brought up on the breast, with a bottle or two a day of cow's milk. The mother 
was menstruating for the first time, and the infant was cutting two lower teeth. His 
mother gave him an enema with a small ball syringe, which brought away a large curdy 
stool. During the night he was very restless, vomiting frequently, and straining con- 
stantly, and at 7 A.M. passed a bloody stool with mucus sufficient to saturate an ordinary 
napkin. We saw him, with Dr. E. H. Smith, of Knutsford, next morning, January 3, 
fifteen hours after the seizure. His face was placid, not drawn or distressed ; there was 
no fever ; the abdomen was flaccid and not distended, and could be easily palpated in 
every part. On deep pressure an elongated tumour was felt ; the left end was most dis- 

1 Lancet, Jan. 8, 1887. 

2 Vide Mortimer, Lancet, May 23, 1891, p. 1144, for an account of experiments upon 
distension. 



Intussusception 139 

.tinct, and was situated in the left lumbar region, just below the ribs and near the tip of the 
spleen ; it could be traced from left to right across the abdomen for two or three inches, 
its outline being gradually lost. It was movable and not tender. No tumour could be 
felt in the right lumbar region or per rectum, but the finger, on being withdrawn, was 
covered with blood. We at once decided to reduce the invagination, which we believed 
to exist, by distending the colon by water pressure. The attempt proved a failure, as the 
water returned by the side of the catheter into the rectum without distending the colon to 
any great extent. We next tried the inflation of air, by means of an ordinary Higginson's 
syringe, the bone nozzle being inserted into the rectum ; the pelvis was raised, and the 
tumour gently kneaded, while air was forced into the bowel by squeezing the ball of the 
syringe. After four or five squeezes the tension in the colon was felt to be considerable, 
then followed a gurgling noise, and the tumour disappeared. We continued to pump 
more air in, in the hope that we might effect the complete reduction of the invagination. 
The infant seemed relieved, and went to sleep for some hours ; but towards evening the 
straining returned, and he spent a restless night. There was no vomiting ; he passed per 
rectum some flatus, blood-stained mucus, and a little curd. We saw him again next day, 
January 4. There was some distress noticeable now on his face ; he had colicky pains at 
times ; there was no tumour to be felt. A minim of tr. opii was given, and the infant 
was placed in a warm bath for ten minutes. The colon was slowly distended with warm 
water by means of a Higginson's syringe, the infant being in an inverted position ; no 
immediate effect appeared to be produced. Three hours later another minim of tr. opii 
was given. An hour later, after another warm bath, he passed a copious yellow liquid 
stool. From this time he continued to improve, though for a few days he was griped at 
times and passed small quantities of blood and mucus in his stools. Small doses of opium 
were given for a few days. • 

Intussusception ; Injection of Water ; Recovery. — A healthy infant of 5 months, who 
was nursed at the breast for three months, and latterly fed on milk and water, was seized, 
in the evening of February 7, with vomiting and abdominal pain. He had been constipated 
for some time previously, and, for a day or two, more restless than usual. During the 
night he passed some blood per rectum. He continued much in the same state during 
February 8 and 9. We saw him with Dr. Massiah, of Didsbury, on the evening of the 9th. 
There was no distress visible on his face, but he was pale and weaker than usual. • The 
abdomen was semi-distended and flacc'd ; no tumour could be felt, though w r e were able 
to press deeply into the abdomen. He strained at times ; and the finger, introduced into 
the rectum, returned covered with dark decomposing blood. A minim of tr. opii was 
given, and he was put into a warm bath ; chloroform was given, and warm water injected 
per rectum by means of a Higginson's syringe. There w 7 as much straining and resistance 
at first, but this was gradually overcome. It was evident, on percussion, that the water 
reached the ascending colon and caecum. Having distended the bowel three times with 
the water, we resolved to wait and see the effect. After the last injection he vomited some 
stercoraceous fluid. Four hours afterwards he passed a liquid stool and made a good 
recovery. 

These plans are open to the objections, first, that there is distinct danger 
of over-distension and rupture of the bowel, as shown by the experiments of 
Bryant and others ; secondly, that they can only succeed where no adhesions 
have formed between the adjacent peritoneal surfaces ; and thirdly, that 
even if reduction does apparently take place it may be incomplete or invagi- 
nation may recur. A case of our own well illustrates this last fact. 

Intussusception ; Abdominal Section; Death. — Harold T., aged seven months, was 
admitted into the Children's Hospital, May 30, 1887, with symptoms of acute intussusception 
of three days' duration. The invagination could be felt externally in the left iliac region, 
and internally per rectum. Under chloroform inflation was employed without success ; 
ten ounces of water were then injected through an india-rubber tube three feet long, with 
the result of causing disappearance of the tumour and increase of resistance previously 
deficient in the right iliac area. He slept quietly for some hours, and then began to scream 



140 Diseases of the Digestive System 

again, and the intussusception reappeared. Injection was again apparently successful, 
and the child spent a quiet night. The next afternoon the symptoms reappeared, but 
were once more relieved by injection. The next day the general condition was worse, and, 
as it was clear that no complete reduction had taken place, abdominal section was per- 
formed, the intussusception found and reduced ; the bowel was inflamed but not gan- 
grenous, there were no adhesions, and the invagination was ileo-caecal. The child sank 
and died an hour later. 

(3) Abdominal section may be performed and the obstruction relieved by 
more direct means. The section is best made in the median line below the 
umbilicus, the bladder having been previously emptied. As soon as the 
abdomen is opened, the intussusception should be drawn to the surface and 
carefully examined. If the bowel is in good condition a careful attempt 
should be made by gentle traction to withdraw the ' intussusceptum.' Re- 
duction is sometimes best managed by squeezing the tumour and drawing 
the ' intussuscipiens ' off the ' intussusceptum/ rather than by directly pulling 
out the invaginated gut. If this can be done and the bowel is not too much 
injured for recovery, it should be left to itself and the wound closed. 

Intussusception; Abdominal Section. — In a case which we saw with Dr. Cox, of 
Eccles, his patient, a child of eight weeks old, had symptoms of twelve hours' duration. 
With the help of Drs. J. J. and F. Cox and Hutton, an attempt was made to reduce the 
invagination by injection ; this partially succeeded, but a nodule could still be felt in the 
right hypochondrium. We therefore opened the abdomen and drew up this nodule, 
which consisted of the caecum with the small intestine entering it. At this point there 
had been evidently a previous local inflammation, since the parts were much thickened 
and indurated, and the adjacent glands were enlarged. The intussusception had been 
reduced, and nothing more appeared necessary. The abdomen was closed, and the 
child got quite well. It, however, unfortunately died of pneumonia three or four weeks 
later. 

If the bowel, however, is too much injured to have a reasonable chance 
of recovery, or if the intussusception is irreducible, one of three courses must 
be followed — either the bowel must be opened above the tumour and an 
artificial anus made, the invagination being left to itself, or the intussus- 
ception must be resected and the two ends of the gut stitched together, or 
finally, after resection the two ends may be brought out of the wound and 
fixed to its edges, an artificial anus being made. The plan of leaving the 
intussusception alone has no advantages, inasmuch as the injured bowel will 
almost certainly act as an irritant and set up peritonitis. The plan of re- 
section and suturing together the ends of the bowel, if successful, gives, of 
course, the most perfect result ; but it is open to the objection that it is long* 
and tedious, and the child is likely to die of exhaustion, and, further, there is 
danger of leakage even after the most careful suturing. If this plan is 
adopted, it is probably wise to use Barker's plan of resection of the intussus- 
ceptum from within the gut, or one of the many other modes of uniting the 
ends of the bowel may be employed. Of these that by Murphy's button is 
probably the quickest method ; but in the absence of any of the special appli- 
ances, simple direct suture by Lembert's method may be employed. The least 
dangerous course, if the child is very feeble, is to resect the tumour and fix 
both ends of the gut to the abdominal wound. Subsequently, i.e. after 
several weeks, should the child recover, an attempt may be made to restore 



Intussusception 1 4 1 

the natural channel and close the artificial anus by the usual method. The 
ends of the bowel may be dissected away from the edges of the wound and 
united to one another by sutures or other method. This, though a less 
showy plan and one requiring more prolonged treatment, is safer at the time 
than the other method of immediate union after resection, though in a case 
where the child appeared well able to bear the more severe operation, 
immediate union is the proper course, especially if suitable appliances are at 
hand. The utmost care in all cases must be taken to prevent the escape of 
the intestinal contents into the peritoneal cavity : this is managed by 
emptying the segment of gut dealt with before opening it, and keeping it 
empty by pressure of an assistant's fingers or a clamp, such as a pair of 
forceps shielded with soft rubber and fixed very lightly on the bowel, so as 
not to bruise it, or a better and simpler plan is that of tying a piece of 
rubber tube round the ends of the gut. All blood &c. must be carefully 
cleaned out of the peritoneum. 

Given, then, a case of acute intussusception, inversion and injection 
may first be gently tried ; should these means be successful as shown by 
the bowels acting, well and good ; if after injection the tumour disappears, 
it is well to wait for a few hours to see whether the bowels are relieved. If 
injection proves successful, the child should be kept under the influence of 
opium, and the pelvis raised above the level of the head. If, however, the 
tumour does not disappear, or if, in spite of its disappearance, or of course 
in its absence from the first, the symptoms persist, immediate laparotomy 
with reduction of the invagination, if possible, should be performed, and if 
not reducible the tumour should be resected and dealt with by one of the 
methods mentioned. The balance of surgical opinion appears to lean 
towards the view that immediate abdominal section is the safer and wiser 
course. The results of injection are uncertain, its use is dangerous, and 
delay in reduction of the intussusception is so disastrous that probably more 
lives would be saved by immediate operation than by any other treatment. 
For further details, we must refer to the general text-books or to Mr. Treves's 
work on Intestinal Obstruction, or to Mr. D'Arcy Power's Hunterian Lectures, 
1897. 

Chronic intussusception is exceedingly rare in children, except, perhaps, 
as one form of so-called prolapse of the rectum, which is really intussuscep- 
tion of the upper into the lower part of the bowel. A chronic invagina- 
tion may, however, occur elsewhere ; its duration may be weeks or months ; 
Treves records a case of a year's standing and a doubtful one of many years' 
duration. We have had a child under the joint care of our colleague 
Dr. Hutton and ourselves in which a chronic intussusception of the ileo- 
cecal variety existed for a year, and which ultimately died of faecal extrava- 
sation from gangrene found at the time of abdominal section. The whole 
tumour was soft and pulpy, there was intermittent constipation, no vomiting, 
tenesmus, or bleeding, much distension with visible peristalsis, at times, at 
others a flaccid abdomen ; no definite tumour was to be felt in the rectum 
or abdomen, and, in fact, the symptoms in this case, as in most of those on 
record, were very uncertain, and not at all characteristic of intussusception. 
Enterotomy or resection was the only thing that could have relieved this 
case, and if the symptoms were at all urgent we should recommend it in 



142 Diseases of the Digestive System 

another case, reduction of the invagination being quite impossible. The 
bowel in these cases sometimes sloughs away as in the acute form. In the 
simple rectal form the prolapse is usually reducible, and if so can be cured 
by rest, avoidance of straining, and, if necessary, the use of the cautery as in 
other cases. It is of the utmost importance that the motions should be 
passed in the recumbent position, and should be kept soft by doses of cod- 
liver oil or by olive-oil enemata. ( Vide Rectal Prolapse.) We have 
recently (1895) seen with Dr. Cox a child in whom there were symptoms 
suggestive of intussusception, though there was no bleeding or tenesmus. 
There was obstruction, with a palpable oval tumour lying on the right side 
of the umbilicus, and closely simulating an intussusception. We, however, 
came to the conclusion that the case was one of tubercular mesenteric 
glands, which by pressure or traction caused the obstruction, and on opening 
the abdomen this view proved correct ; the tumour was a large mass of 
glands caseating and breaking down, and other enlarged glands were found. 
The manipulation relieved the obstruction, but the child was too ill to bear 
removal of the glands, and died a few days later. 

We have recorded in conjunction with Dr. Knowles Renshaw ' a case of 
intussusception of the vermiform appendix into the caecum treated by 
removal of part of the appendix. Reduction was only partially effected even 
after opening the caecum and pushing out the intussusception from within. 
The lumen of the bowel was not, however, seriously obstructed, and the 
child completely recovered. Other cases of this condition have been put on 
record by Chaffey, Pitts, and others. 2 Since there is no obstruction in 
these cases the symptoms are not acute. The occurrence of an intussusception 
through a persistent Meckel's diverticulum has been already mentioned. 

Chronic Obstruction of the Bowels. — Reference has already been made 
to the constipation of infants and older children, due to an atonic 
condition of the colon or a chronic intestinal catarrh ; but other causes of 
inactive bowels exist which are attended with serious inconvenience, and 
even fatal results. Occasionally fibrous bands due to old, perhaps a fcetal 
or to tubercular peritonitis, mat together the coils of intestine, more 
especially the lower part of the ileum, and consequently check or interfere 
with the peristaltic action of the bowels. It appears also that occasionally 
the sigmoid meso-colon and meso-rectum are snorter than usual, fixing the 
lower bowel, and perhaps more or less forming a kink at its natural curves, 
where hardened faeces may lodge and a temporary obstruction take place. 
A fatal case, which seems to have been due to this cause, is recorded by 
Dr. Eustace Smith, the patient being a boy of 8 years who died shortly 
after coming into hospital. Whatever may be the cause, cases not 
infrequently come under observation where 'the child has suffered from 
constipation all its life, large accumulations of faeces taking place in the 
colon which have to be removed by enemata, and where the bowels, if left 
to themselves, only act once or twice a week. In some of such cases an 
enormously dilated colon has been found after death with superficial 
ulceration of its mucous membrane, the cause of such dilatation being by no 
means clear. In two of these cases which, by the kindness of Dr. W T ilkinson, 

1 Brit. Med. Jour. June 1897. 

- Vide Treatment, November 2;, 1897. 



Chronic Obstruction of the Bozuels 143 

we have been able to see, the distension was at times enormous. In one we 
did inguinal colotomy, and found the intestine full of frothy fluid. The child 
died shortly after the operation. In one instance Mr. Treves removed the 
colon with a good result. It must not be forgotten also that a chronic intus- 
susception may exist for many months, and give rise to the symptoms of 
chronic obstruction. A careful examination of the abdomen should be prac- 
tised in order to ascertain the presence of a tumour, and to determine if pos- 
sible its nature, whether due to collections of hardened fasces, matting of the 
omentum and intestines, as in chronic peritonitis, or to the presence of an 
invaginated bowel. An examination of the rectum should always be made. 
The possibility of obstruction being due to pressure of an abscess or growth 
in the pelvis, or to the presence of a foreign body in the bowel, must also be 
borne in mind. 



144 Diseases of the Digestive System 



CHAPTER VIII 

DISEASES OF THE DIGESTIVE SYSTEM— {continued) 

Tubercular Ulceration of Bowel and Mesenteric Disease 

In the majority of cases of children dying of tubercular disease, tubercular 
ulcers are present in the intestines, and the mesenteric glands are enlarged 
and ' cheesy' on section. This association of ulceration of the intestines with 
cheesy mesenteric glands is so much the rule that it is impossible to separate 
the two clinically, and it must also be remembered that anatomically the 
solitary glands and Peyers patches are lymphatic structures. The frequency 
with which these lesions complicate phthisis or general tuberculosis is shown 
by the fact that in 103 consecutive post-mortems made at the General 
Hospital for Sick Children, Manchester, on children of all ages dying of 
tuberculosis, in 62 there was tubercular ulceration of the intestines, in 71 
cheesy mesenteric glands, in 55 both ulcers and cheesy glands existed 
together, in 7 tubercular ulcers without cheesy glands, in 16 cheesy glands 
without ulcers. (See also TUBERCULOSIS, Chapter XIII.) These numbers, as 
far as the frequency of tubercular ulceration is concerned, do not overstate 
the fact, as it is far more likely that the presence of ulcers in the intestines, 
especially if they are small, should be overlooked, than their frequency over- 
rated. These statistics also show the frequent association of ulceration of 
the* intestines and disease of the mesenteric glands, though this association 
is not constant, and one may be found occasionally without the other. 
Ulceration may exist without the mesenteric glands joining in the process, 
but there is a strong probability, amounting almost to certainty, that if ex- 
tensive ulceration be present the glands will be found to be affected. On 
the other hand it is certain that ulceration is not the necessary precursor of 
mesenteric disease ; for just as a chronic catarrh of the nasal mucous 
membrane may in an unhealthy subject set up glandular enlargement 
and abscess, so a catarrh of the intestine, if long continued, is exceedingly 
apt to give rise to mesenteric diseas^e. Although mesenteric disease is so 
commonly found in children dying with a widespread distribution of tubercle, 
it is by no means so common to find tubercular disease beginning with 
symptoms of tabes mesenterica, as is commonly believed, for in practice it 
is constantly found that infants and children who have habitually distended 
abdomens, with more or less wasting, are put down as suffering from ' con- 
sumption of bowels.' In the greater number of these cases there is no 
mesenteric disease, but a chronic and obstinate catarrh of the intestines 



Tubercular Ulceration of Bowel 145 

which is perfectly remediable. Besides the very frequent association of 
ulceration and mesenteric disease, chronic tubercular peritonitis is a frequent 
complication. 

Infants and children of all ages suffer from tuberculosis of the intestines 
and glands, but it is perhaps less common before the age of one year than 
afterwards. The common cause of marasmus in infants is a gastro-intestinal 
atrophy rather than tubercular disease, such infants succumbing before the 
tubercular process is set up, though in some cases cheesy glands may be 
found. It has just been noted that in at least 7o per cent, of cases dying of 
tuberculosis, disease of the mesenteric glands was present, and in rather 
more than 55 per cent, tubercular ulceration was associated with it ; it is of 
some interest and importance to inquire in how many of these cases was the 
tuberculosis of the intestine and glands primary, and the tubercular lesions 
elsewhere secondary; and in how many instances the tubercular disease 
began with abdominal symptoms. A primary tuberculosis of the intestine 
is suggestive of infection by means of tubercular bacilli taken in food, as, 
for instance, in the milk from a cow with tuberculous udder. (See TUBER- 
CULOSIS.) 

Of the 103 fatal cases of tuberculosis referred to above, in 13 or about 
12 per cent, the early symptoms were referable to the abdomen ; in a few of 
the cases, symptoms of lung mischief were absent during life, and the lungs 
were found free from tubercle, or only slightly affected ; in the majority of 
cases the physical signs and symptoms pointed during life to lung compli- 
cations, which supervened sooner or later, and at the post-mortein more or 
less extensive pulmonary lesions were found, though in some instances these 
only appeared during the last fe\v weeks or months of life. Tubercular 
ulcers are most frequently found in the ileum, and in the large bowel, especi- 
ally in the caecum. In chronic cases they may be very extensive, with much 
matting together of different coils of intestine and of the omentum by peri- 
tonitis. The walls of the caecum are often much thickened. The ulcers, if 
recent, are sharply punched out ; if chronic, their edges are thickened and 
irregular, mostly running' across the gut. The mesenteric glands when 
affected are enlarged and cheesy ; sometimes a few, at other times nearly all 
the glands seem to have undergone cheesy changes ; occasionally suppura- 
tion takes place. The ulcers may cicatrise, and by puckering the gut give 
rise to some obstruction to the passage of the intestinal contents, especially 
in the large bowel or at the caecum. 

Symptoms. — If a child of over two years of age suffers from a chronic 
looseness of the bowels, with wasting and hectic, there is a strong probability 
that it suffers from abdominal tuberculosis. This probability passes more or 
less into a certainty if it comes of a tubercular stock and presents the usual 
tubercular aspect, such as marked pallor, long curved eyelashes, and excessive 
growth of fine downy hair upon the skin. The abdomen is usually more or 
less distended with gas, the superficial veins are enlarged, there may be 
tenderness on deep pressure, and perhaps some thickening may be felt over 
the caecum, or some matting of the omentum. The symptoms are often 
varied according as ulceration of the bowels, mesenteric disease, or chronic 
peritonitis is extensively present. In most cases of tubercular ulceration 
there is troublesome diarrhoea, though it must be borne in mind that this 

L 



146 Diseases of the Digestive System 

diarrhoea in many cases completely stops for a while, or, indeed, max be 
absent from first to last. There is no special feature about the diarrhoea of 
tubercular disease ; there is a general tendency to looseners, and colic may 
come on after errors in diet, or directly after food is taken, or may appear to 
be the result of cold. The stools are mostly liquid and brown or yellow with 
an excessive quantity of mucus and perhaps streaks of blood, but too much 
stress must not be laid upon the character of the stools. The tongue is 
usually clean and red, with enlarged and congested fungiform papillae. It is 
of course necessary to carefully examine the lungs in all such cases, as any 
confirmatory evidence of tuberculosis there would be of great importance 
from a diagnostic point of view. The course of such cases is often chronic, 
and they often greatly improve for a while, probably on account of the intes- 
tinal catarrh which is present undergoing improvement, 01 the ulcers may 
slowly cicatrise and heal. On the other hand, there is a constant risk of a 
tubercular meningitis supervening, or some acute lung trouble carrying them 
off. Sooner or later, however, the diarrhoea, wasting, and hectic reappear, 
the child becomes more and more pallid, the abdomen more distended, the 
feet swollen, and the face puffy. The diarrhoea at the last is often constant, 
and the desire to go to stool, only a little mucus or liquid faeces passing, 
is very distressing and not easily relieved. The emaciation at the last is 
often extreme. When symptoms of abdominal tuberculosis follow on those 
of chronic tuberculosis of the lungs, the diagnosis is not difficult, and a more 
rapid course may be predicted. When the tuberculosis of the intestines 
is primary and uncomplicated with other trouble, the course may be very 
chronic, extending over several years, improvement taking place from time 
to time. 

In rare cases severe haemorrhages may occur from tubercular ulceration 
of the intestines. This takes place, as would naturally be expected, in the 
acute rather than in the chronic cases, as in the late cases thickening and 
cicatrisation take place. We have known fatal haemorrhage from the bowel 
to take place from a tubercular ulcer of the ileum. 

In the following case there was severe haematemesis, and some dark 
blood was also passed by stool. The case was puzzling, as at the time the 
vomiting of blood took place there was nothing in the lungs or abdomen 



Acute Tuberculosis; Ulcers in the Jejunum ; Severe Hcematemesis. — William T. , aged 
10 years. He was, it was stated, always a strong boy till a fortnight before his admission, 
when he complained that he was lame in his right leg ; both knees were painful and 
swollen. Admitted June 18. He was a well-nourished boy ; all the organs were normal ; 
his appetite was bad ; there was no diarrhoea. The right knee was swollen ; there was a 
suspicion of early hip disease on the right side. The evening temperature reached 102 ; 
the evening temperature continued raised a degree or two for a few days, and then became 
normal. He complained for the next week or two of great pain in his knee. On July 11, 
after having had a good dinner, he suddenly vomited a quantity of bright blood with large 
clots, and quickly became blanched ; twice during the day he again vomited dark blood. 
There was some tenderness and resistance on the left side of the abdomen, just below the 
ribs. He remained fairly well till July 18, when he again vomited some half-pint of blood 
and mucus ; there were large quantities of dark blood in his stoo's. July 28. — He has wasted 
much in the last few weeks ; there is no cough or diarrhoea. From this date till his death 
the temperature was hectic, varying from ioo° to 103 ; rales were heard in his lungs, 



Tubercular Ulceration of Bozvel 147 

especially at the apices, and it was evident he was suffering from acute tuberculosis. He 
gradually became extremely emaciated ; there were no more haemorrhages. He never 
suffered from any diarrhoea. Death occurred September 27. At the post-mortem, both 
lungs were studded with clusters of tubercles, becoming caseous at the right apex ; the 
mediastinal glands were caseous. The stomach was healthy ; the mesenteric glands were 
swollen, but not caseous ; there were some large, recent, sharply cut tubercular ulcers in 
the middle of the jejunum, and numerous others in the ileum and large bowel. Miliary 
tubercles on the spleen and liver. Early tubercular hip disease. 

In those cases where the mesenteric glands are chiefly affected the 
symptoms are still less definite, though this, as has been pointed out, is not 
often the case, as varying degrees of tubercular ulceration of the intestines 
and chronic cicatrising peritonitis are apt to be present. The symptoms are 
usually those of chronic intestinal catarrh, perhaps without marked diarrhoea, 
with wasting and hectic. It must be remembered that a distended abdomen 
which is chronically in this condition, with some wasting and an evening 
exacerbation of temperature, does not necessarily mean mesenteric disease, 
any more than the signs of a chronic pneumonia are necessarily to be inter- 
preted as the signs of tubercle ; we only infer in both cases that tuber- 
culosis exists if we get confirmatory evidence elsewhere. A history of 
tubercle in the family, the steady progress of the disease, wasting, great 
pallor and hectic, would help the diagnosis. The supposed large glands 
should be carefully felt for, taking care not to mistake fasces in the large 
bowel or indurations of the mesentery or caecum for enlarged glands. The 
fingers should be laid on the abdomen below the umbilicus and pushed well 
in, and gently moved about ; the mesenteric glands lie deeply, can rarely be 
distinctly felt, they are movable, and of size varying' from hazel nuts to 
walnuts. If the abdomen is distended with gas, even large groups of glands 
may exist, and yet not be felt. An early diagnosis is rarely possible by dis- 
covery of enlarged glands ; it is only towards the close that they can usually 
be felt, when the tonus of the abdominal muscles is diminished and the 
intestines more or less collapsed. 

Diagnosis.— A child with a temperature raised a few degrees at night, 
with distended abdomen, chronic diarrhoea which resists treatment, and 
has produced wasting and marked pallor, is probably the subject of 
tubercular ulceration of the intestines. If, at the same time, local indura- 
tions can be felt in the region of the caecum or in other places, or if there are 
signs of tubercular disease in the lungs, the diagnosis becomes still more 
probable. Moreover the diarrhoea probably persists in spite of liquid diet, 
rest in bed, and astringents, and is only temporarily kept in check by opium. 
Mesenteric disease is much more frequently diagnosed than discovered post 
mortem. A progressive wasting due to chronic intestinal catarrh or gastro- 
intestinal atrophy is frequently attributed to caseous degeneration of the 
mesenteric glands, and a fatal termination is looked upon as inevitable. It 
is well, however, to bear in mind that mesenteric disease is uncommon before 
eighteen months or two years of age, and, moreover, great wasting may be 
due to intestinal catarrh without mesenteric disease. It is but seldom that 
enlarged glands can be felt ; the diagnosis mainly depends upon the signs of 
tubercle elsewhere in the body and upon the family history. If there has 
been much diarrhoea with hectic, and symptoms of chronic peritonitis, 

l 2 



148 Diseases of the Digestive System 

followed by extreme wasting, there is good reason to suspect mesenteric 
disease. 

Treat )tie?it. — The treatment of tubercular ulceration and mesenteric 
disease is the treatment of tuberculosis in general. Fresh air and careful 
dieting are all-important. The special treatment consists in keeping the 
diarrhoea in check, while nourishing food easy of assimilation is being sup- 
plied to the patient. The class of foods must be selected from those which 
contain much nutriment in little bulk, such as eggs, fish, meat, fats, milk, 
rather than foods containing large quantities of starch and sugar. If there 
is but little diarrhoea, milk may be allowed in moderate quantities, but the 
amount taken must not be excessive if much looseness of the bowels exists, 
as too much fluid taken is apt to aggravate the diarrhoea. In all stages of 
the disease minced underdone meat, whether chicken, beef, or mutton chop, 
is of great value. The child's portion may be taken from red juicy meat 
found close to the bone in a large joint of roast beaf. It should be finely 
minced, cut as fine as it is possible to cut it, and gravy poured over 
it before it is taken. Of this, large quantities will be taken readily by the 
children, some crumbs of stale bread being given with it ; but even small 
quantities of starch are apt to disagree and give rise to flatulence. An egg 
-or part of an egg beaten up in milk may be given once or twice a day. The 
diarrhoea is best kept in check by careful dieting, avoidance of more food 
than the child can digest, and if excessive, the food for a while must consist 
almost entirely of pounded underdone meat or meat juice. Small doses of 
opium combined with mercury and chalk may be given. (F. 41, 42.) 

In the later stages small enemata of laudanum and starch may be re- 
quired, but too often the diarrhoea is quite uncontrollable. Opium fomenta- 
tions are useful. If the diarrhoea is due to the presence of indigestible food, 
laxatives such as a powder containing rhubarb and soda should be given. 
Cod-liver oil, either as an emulsion or in combination with other tonics, is 
■useful in all stages except when diarrhoea is excessive. (F. 43, 44.) 

Congenital Obstruction of the Bowels. — It is not an uncommon cir- 
cumstance for a newly born infant to suffer from complete obstruction of 
the bowels : passing no meconium, though the rectum may be normal, and 
shortly after being put to the breast it may vomit, first milk, then bile, 
and finally meconium. In the meantime the abdomen becomes dis- 
tended, the face pinched, and the infant dies in a few hours, or perhaps 
lingers for a few days. At the post-mortem various obtructive lesions may 
be found. There may be a stenosis of the duodenum, jejunum, or more 
frequently the ileum, the gut perhaps being narrowed or even reduced to a 
.mere band of fibroid tissue which runs along the free edge of the mesentery 
for perhaps several inches, and opens out again into normal bowel lower 
.down ; this cicatrisation of a portion of bowel may have been produced by a 
foetal peritonitis, or it is the result of a mal-development. In the following 
case it was apparently the latter : 

Congenital Occlusion of the Duodenum (Dr. T. B. Grimsdale's case).— The mother 
•was a healthy woman -who had had five children previously. The first was still-born ; the 
four others all suffered from symptoms of obstruction and died on the third day after 
birth. The sixth child appeared healthy and well nourished at birth, and for the first two 
.days seemed quite well. Tor the last two days it was a peculiar colour— a sort of orange 



Obstruction of the Bowels 14.9 

purple tint. It only vomited once shortly before death ; it was convulsed before death. 
At the autopsy the stomach and upper part of the duodenum were distended with fluid ; 
the duodenum was found to terminate in a cul-de-sac about two inches from the pylorus. 
The rest of the intestines were well formed though small ; the bile duct opened into the 
duodenum below the obstruction. 

In the following singular case there was an obstruction of the jejunum, 
presumably due to a fcetal peritonitis and possibly some chronic inflamma- 
tory lesions after birth : 

Congenital Obstruction of the Jejunum ; Dilated Stomach and Duodenum. — W. M. , 
aged 15 years, seen with Mr. C. R. Graham, of Wigan. His mother srave the following 
history : He was nursed at the breast for some months, and during this time he was sub- 
ject to periodical attacks of severe vomiting ; these attacks were much more severe than 
infants are usually subject to. The vomiting began immediately after birth ; the vomited 
matters consisted of curd and bile. These attacks of vomiting have occurred at intervals 
of a week or two all his life. On more than one occasion the attacks have been so severe 
and long continued that his life was despaired of.' He has vomited as much as six to 
eight pints in one night. He went, on one occasion, a voyage to the Mediterranean, but 
had to be landed on the first opportunity, as the constant vomiting had so exhausted him 
that his life was in danger. Sometimes he would suffer from colic and nausea but did not 
vomit. Errors of diet, excitement, or worry all seemed to excite an attack. A physical 
examination showed a dilated stomach ; the abdomen was also more or less distended. 
The symptoms and physical examination pointed to a dilated stomach, secondary to some 
congenital obstruction in the upper part of the bowels. The vomiting attacks continued 
during the next four years, up to the time of his death, when he was nineteen years old. 
We are indebted for details of his last illness to Dr. Sutcliffe, of Jersey, where he died. 
He seemed in his usual health on December 6, 1890, and joined in a game of football. 
The same evening he had one of his usual vomiting attacks, which was more severe 
than usual, and Dr. Sutcliffe was sent for. When seen on December 8, he was evidently 
suffering from acute obstruction of the bowels : the vomiting was continuous, and nothing 
was passed per rectum. There was intense collapse. Death took place on the fourth day 
of his illness. Post-mortem made by Mr. Graham and ourselves : The body was that of 
a well-grown but thin youth. On opening the abdomen the small intestines were seen to 
be intensely congested and of a dark purple colour ; there was some lymph on the surface ; 
the parietal layer of the peritoneum w-as much injected. The whole of the small intestines 
were evidently strangulated, there being a complete volvulus ; the last foot or so of the 
ileum was wound tw r o or three times round the upper part of the jejunum, the latter being 
twisted on itself, so that the jejunum, mesentery, and blood-vessels were strangulated ; the 
caecum was dragged upwards out of its place. The immediate cause of death was the 
volvulus, probably the result of severe vomiting. A further examination showed the cause 
of his vomiting attacks. The stomach and duodenum were immensely dilated and hyper- 
trophied, the duodenum looking like a second stomach ; at the junction of the duodenum 
with the jejunum, the gut was bound down and surrounded by fibroid adhesions for some 
six inches, and one spot was contracted so as only to admit the forefinger. The fibroid 
mattings were presumably the result of some inflammatory lesion taking place before birth. 

In another instance we were called to see a patient of 26 years of 
age with intestinal obstruction. Before seeing him we were told as a re- 
markable peculiarity that he had gone on growing until the time of his 
illness, i.e. his 26th year. We found a tall, thin, ill-developed, youthful- 
looking man, dying of intestinal obstruction. On opening the abdomen 
there was general peritonitis, the intestines were inextricably matted 
together by old adhesions as well as by recent lymph. Nothing could 
be done. The testes though in the scrotum were very small and uncle- 



I 50 Diseases of tlie Digestive System 

veloped, and there were practically no signs of puberty. It appears 

likely that the arrest of development was the result of the old and probably 
foetal peritonitis which was ultimately the cause of the obstruction. The 
abnormal prolongation of the period of growth was probably due to the 
same lack of development of adult characters. He died at the time of the 
operation. 

In a few cases a twist in the lower end of the ileum has been found. In 
rare instances, a new growth or hernia has occurred, or a knuckle of bowel 
has been found tied up by some band or persistent omphalo-mesenteric duct. 

Obstruction of the bowels in infants a few weeks or months old may be 
due to a congenital lesion which has caused a partial obstruction, which is 
rendered complete by the impaction of hard curdy feculent matters. 

In all cases of vomiting with signs of obstruction of the bowels, a care- 
ful examination of the anus and rectum should be made (See also p 142.) 

Imperforate Anus. — The iower segment of the large intestine, including 
the sigmoid flexure and rectum, is very liable to important malformations. 

In the first place there may be mere malposition, the sigmoid flexure de- 
scending on the right side or in the middle line instead of on the left ; this 
would not necessarily give rise to any inconvenience during health, and 
would be mainly of importance should there be any disease of the bowel in 
later life. 

The more immediately important conditions are the various forms of 
obstruction of the lower bowel from want of development of some part of it, 
or the presence of abnormal openings from imperfect differentiation of the 
digestive and genito-urinary segments of the cloaca. 

Several varieties of malformation are found. There may be a well-formed 
anus, but communication between this and the rectum may be cut off by the 
presence merely of a membrane which has persisted from the time when the 
epiblastic involution — proctodeum — dipped in to meet the intestine. {Imper- 
forate rectum.) Sometimes the rectum itself is deficient altogether or for a vary- 
ing distance, the anus also being undeveloped. In other instances the rectum 
is well formed, but the anus is absent. {Imperforate aims.) In these varieties 
there is no external opening at all, and the meconium is retained. Some- 
times the anus is undeveloped, and the rectum, instead of ending blindly, opens 
into the anterior or genito-urinary segment, i.e. into the urethra or bladder, 
or, much more commonly in the female, into the vestibule, not into the 
vagina, as is commonly stated ; the vaginal orifice in these cases is nearly 
always in our experience seen in front of the rectal outlet. We have only 
once met with a case of the rectum opening into the vagina itself ; this was 
in a child kindly sent us by Dr. Cullingworth, who thinks it is not an 
uncommon condition. Bodenhamer, out of 287 cases, found 85 opening 
into the vulva or urinary tract, while in 53 there was no anus and the rectum 
ended blindly ; these are the two most common types. 

Occasionally a ' tablike fold of skin ' passing from the scrotum to the 
coccyx obstructs but does not close the anus (Cripps). Edge has recorded a 
more complete case where the anus was double and the rectum imperforate. 
We have met with a case where a single anus led up to a double gut above. 
Rarely there is an unnatural anus in the groin or in communication with the 
bladder, or, as in a case of Erichsen's, a fistula below the umbilicus ; scrotal, 



Imperforate A nus 1 5 1 

penile, and perineal fistulas have also been met with as well as congenital 
stricture of the rectum which was not actually imperforate. ( Vide Prolapsus 
Recti.) As a less important condition mere tightness of the anus may also 
occur. 

When the anus is present, but there is no communication with the bowel, 
the malformation is often overlooked at first, and it is thought that the infant is 
simply constipated ; in such cases purgatives are often given and the child's 
distress much increased. Constant crying, distension of the abdomen with 
visible intestinal coils, and subsequently vomiting and collapse come on, and 
unless an examination with the finger is made and the obstruction discovered 
the child dies exhausted. On examination it will be found that the finger 
can only be passed a very short distance ; if the rectum is developed and 
there is only a membranous septum, the bulging of the gut as the child 
strains will be plainly felt, but should the bowel end higher up this sensation 
may not be distinguishable. 

Where the anus is absent and the rectum ends just above it, as according 
to Cripps it usually does, though in our own experience the common condi- 
tion is a well-marked proctodeum but no rectum, the bulging will often be 
readily made out, but if the rectum ends higher up there may be no 
impulse ; in such cases the perineum is narrow and the pelvic outlet smaller 
than it should be. When there is no anus the rectum is generally nearer the 
surface than when an anus is developed, but the rectum ends blindly. 

Where the rectum ends high up in the pelvis, a fibrous cord may be 
prolonged downwards in the position of the natural bowel ; this cord was 
thought by Mr. Curling to represent the rectum obliterated by intra-uterine 
ulceration ; its presence, however, is not constant. 1 

When the rectum ends in the urethra there is a passage of fluid faeces and 
flatus by the urethra, together with absence of the natural orifice. Subse- 
quently, if the child survives, there is much trouble from obstruction of the 
urethra by faecal matter and from irritation set up by the decomposed urine. 
Kelsey 2 points out that if the opening is into the bladder the meconium is 
mixed with the urine, while if it is urethral the bowel contents may escape 
independently of the urine. When the rectal outlet is within the vestibule the 
bowels may be sufficiently relieved for the deformity to escape notice, and 
there maybe no impairment of health ; indeed, the presence of such malforma- 
tion may remain unknown until adult life. In many cases, however, though 
the opening is sufficient for the escape of the fluid or soft faeces of child- 
hood, it is not large enough to allow the passage of solid motions, and 
obstruction arises later on. There is no incontinence of faeces in these 
patients, the internal sphincter preventing involuntary escape. 

As in so many other congenital malformations, a large number of chil- 
dren the subject of these deformities do not survive birth. Where, however, 
a living child is found to have no outlet at all for its intestinal contents, 
immediate treatment is of course necessary, although it is said that patients 
have grown up and relieved the bowels by periodical vomiting of faeces. 
As soon then as the deformity is recognised, a decision must be come to as 
to what is the best mode of relief. 

1 Vide Parker, Path. Soc. Trans. 1884. 2 Archives of Pediatrics. 



152 Diseases of the Digestive System 

Treatment. — When a thin septum alone closes the gut a simple crucial 
incision, using a speculum if necessary, and subsequent dilatation with a 
bougie or the finger, is all that is required. The child, if it survives, may in 
no way suffer afterwards, though we have seen a case of a girl of 10 or 12 
years old who had been operated on in infancy and had not got perfect 
control over the bowels. 

Where the separation between the rectum and the surface is greater, 
bulging of the distended gut should be carefully felt for and an incision made 
just in front of the coccyx and carried down to the bowel, which should then 
be freely opened and brought down and stitched to the skin, unless there is 
so great tension that the stitches are not likely to hold, in which case the 
opening shonld be packed with gauze to keep it patent, or a large drainage 
tube inserted. 

If no bulging can be felt, an attempt to reach the bowel should still be 
made by a similar incision, and the dissection should be carefully carried up- 
wards, keeping well back in the hollow of the sacrum and feeling from time to 
time for the bowel. As it is most important that the child should strain, 
chloroform should only be given during the first steps of the operation, 
and fortunately this is the most painful part of it. With a similar object 
it has been advised to delay operation until the bowels are distended ; this is 
not, however, a wise course. If the gut is found, it should be treated as in 
other cases, or if it cannot readily be brought down, it must be left but kept 
patent in a similar way, or a tube may be kept in through which faeces can 
pass. Amussat and Verneuil resected the coccyx and lower part of the 
sacrum in order to bring the gut to the surface. 

Should it be impossible to reach the bowel from below by dissection, 
which may be carried to a depth of an inch and a half, in no case must 
any blind puncturing with a trocar in hopes of finding the gut be employed ; 
by such means there is much more likelihood of puncturing the peritoneum, 
especially as it usually descends lower than in normal anatomy. Either 
Littre's operation of opening the bowel in the groin or Amussat's (Callisen's) 
lumbar operation must be performed. As there is some uncertainty in 
all these cases as to the course of the bowel, and as in a certain proportion 
the colon lies in the middle line or to the right side, it is wiser on the whole to do 
Littre's operation. The danger of opening the peritoneum is not so unequal 
in the two plans as might be thought, since there is often a mesentery 
in these cases, and the anus is much more conveniently placed for 
self-management in after life ; there is little choice in the matter of danger 
between the two. Littre's operation then should be selected. The operation 
consists in making a vertical or oblique incision about two inches in length 
in the left groin above and a little external to the middle of Poupart's 
ligament ; a vertical incision is probably the best, since, if the sigmoid 
flexure does cross to the right, a slight upward prolongation of the incision 
will enable the surgeon to reach it. The abdominal wall having been cut 
through and the peritoneum opened, the distended bowel will present at the 
opening and should be picked up with forceps, and treated as in the ordinary 
colotomy operation. 1 If the child can bear the delay in opening the bowel, 

1 For a description of the operation we must refer to the general text-books. 



Imperforate Anus 153 

the operation should be done in two stages as in gastrostomy ; to avoid 
leakage Cripps suggests the use of a coarse thread in stitching" the gut to the 
edge of the wound ; the use of a round sewing needle answers better. 

Edmund Owen has six times performed Littre's operation, twice success- 
fully ; three of his cases died from the operation being too late, peritonitis 
existing at the time. In three or four of the instances in which we have done 
inguinal colotomy the result was perfectly satisfactory ; the children got quite 
well for a time, but it is probably rare for such patients to survive childhood. 
It has been suggested that after opening the sigmoid flexure in the groin, a 
probe should be passed downwards and an anus made in the natural position 
with the guidance of the probe. Owen's two successful cases of Littre's 
operation died after the performance of the second operation, but Byrd and 
Kronlein'have been successful. 1 

Curling's statistics and opinion are much in favour of the inguinal 
operation ; Cripps' figures are inconclusive.- Huguier's operation of opening 
the gut in the right groin on the ground of the more frequent position of the 
colon on the right side than the left is not supported by Giraldes' statistics, 
quoted by Holmes, where in 431 autopsies the colon was in its normal position 
in 396 instances ; in eighty of these Littre's operation had been performed, 
and in every case the sigmoid flexure was on the left side. Atkin, of Sheffield, 
records a case in which the small intestine was opened by the inguinal ope- 
ration, the whole colon being rudimentary ; 3 and our colleague, Mr. White- 
head, tells us he operated in the left loin on one occasion and found at the 
post-inortem that the caecum had been opened. 4 

We have opened a coil of large intestine by right inguinal colotomy in 
an adult, and* found that it was the sigmoid flexure and not the ascending 
colon that had been secured. 

Cripps' table gives the following results : 

11 died 



1 w ^ 

3 


5' 


Ul JllgUIIlctl LU1ULU1JI) ... 

lumbar „ 




1 1 

2 


17 


55 


puncture „ 




14 


8 


55 


resection of the coccyx 




5 


39 


55 


perineal incision 




14 


14 


55 


operation for vaginal (i.e. vulvar) 


anus 


1 



„ 3 miscellaneous cases 3 ,, 

Bodenhamer records eight recoveries out of twenty-five Littre's opera- 
tions. 

The deaths are mainly due to peritonitis, or failure of relief. 

Where there is a fistulous opening between the rectum and the bladder 
or urethra, Littre's operation should be performed, unless the gut can be 
reached from the perineum, when possibly the communication with the urinary 
tract may close spontaneously. W T hen the unnatural anus opens in the 
vulva, in the cases we have seen it has usually been by an orifice in the side 
of the distended rectum and not by a terminal opening ; that is, the rectum has 

1 Vide Kelsey, Arch, of Pediatrics, February 1885 ; also Goede vide Cripps. 

2 Vide also Erckelen, Arch. f. Klin. Chir., Langenbeck, 1879. 

5 Lancet, January 31, 1884. 4 Pi lore advised opening the caecum. 



154 Pi senses of the Digestive System 

been pouched and projecting below the vulvar aperture. In such conditions 
a bent probe should be passed through the orifice into the gut and made to 
press against the perineum just in front of the coccyx. An incision is then 
made upon the probe, the rectum freely opened and treated in the usual 
way. Great care must be taken to keep the new aperture patent, otherwise- 
it is prone to contract and the faces continue to pass both ways. In some 
cases it is said that the vulvar orifice will contract and close of itself 
(Holmes). In our own cases we have not found this to occur, and in one of 
them we pared the edges of the vestibular opening and sutured them ; no 
union, however, resulted, and we afterwards laid open the perineum, dissected 
away the gut from the vestibular wall, stitched it carefully to the skin, and then 
sewed up the perineum, with a successful result ; the patient was about 
6 years old. In another instance we performed the same operation in a 
child of 9 months, but it died some weeks later of inanition. We have had 
a third successful case in which power of retention seems well preserved. 
Dieffenbach appears to have been the first to adopt this plan, which, how- 
ever, is often called Rizzoli's operation. It is, we think, well to wait until 
the child is two or three years old before doing the second operation. 

One of the difficulties we have met with in these cases is that of keeping 
the bowels regular even when there is quite a free opening ; this we believe 
to be due to imperfect muscular action, though the muscular coat of the 
bowel is hypertrophied in some of these cases. Enemata, castor-oil emul- 
sion, and occasional more active purges are required under these circum- 
stances. Sometimes when the case is one of vulvar anus a collection of 
hard faeces is found in the intestine above at the time of operation ; this 
requires removal, as the child is often unable to void it even when a good- 
sized aperture has been made. 

Deformities of the Umbilicus. — In some cases of extroversion of the 
bladder there is no trace of an umbilicus to be seen in after life, the scar 
being lost in the malformed abdominal wall. In other cases the umbilicus 
is abnormally large — that is, a considerable part of the abdominal wall 
is formed by the structures of the cord, and sloughs away when the cord 
shrivels up so that an actual deficiency of the abdominal wall results. In 
two cases of this condition we have seen that were operated upon, one by 
Mr. Howse and one by ourselves, a portion of the liver protruded through the 
opening and was covered only by the sloughing tissue. In our own case we 
dissected away the dead part and closed the abdominal openings by sutures, 
but without success ; in a third case, under our care, the part was simply 
protected from irritation and left, but this child also soon died. 1 The fre- 
quent presence of the liver in the hernia has given rise to the name of 
Hepatomphalos, but the stomach and other viscera are often included in the 
protrusion. 

At the third month of intra-uterine life there is still a coil of intestine 
lying in the umbilical cord outside the abdominal cavity ; should this condi- 
tion persist, a true congenital umbilical hernia is found. The importance of 

1 Underwood records a case of recovery in which the treatment consisted in poulticing, 
and Tanner and others have had successful cases. In a case of Brodie's Path. Soc. 
Trans, vol. xv. , besides the hepatomphalos, there was diaphragmatic hernia with defi- 
ciency of the pericardium, and a coil of bowel lay in contact with the heart. 



Deformities of the Umbilicus 155 

this fact is that in ligaturing the cord the gut might be included in the liga- 
ture and strangulated, a mishap that has actually occurred. In slighter 
cases there is only a small protrusion standing out from the abdominal wall 
much like the end of a glove finger ; the bowel is reducible and the treat- 
ment is that of an ordinary umbilical hernia. In other instances, owing to 
persistence of the vitello-intestinal duct, Meckel's diverticulum remains 
open, and passing up to the umbilicus may open there, giving rise to faecal 
fistula, as in a case of our own where a ligature round the protrusion, 
followed by the application of strapping to draw together the sides of the 
orifice, procured closure of the fistula. 1 Edmund Owen advises emptying 
the bowel by free purging" and subsequent administration of opium, thus 
giving time for the fistula to close ; he applies a dry pad over the fistula and 
leaves it undisturbed. Success has followed this treatment, but it appears 
to be applicable to older children rather than to infants. A plastic operation 
on the usual lines for the cure of faecal fistula would be the proper treatment 
in a troublesome case. For pate?it urachus &*c. vide Surgery of the 
Urinary Organs, vide also Diseases of the Navel, 

Congenital hiatus of the abdominal wall may occur in other parts besides 
the umbilicus from simple failure of closure of the ventral laminae. Of this 
extroversion of the bladder is an instance. In some cases the recti fail to 
meet one another in the middle line, and ventral hernia may result with great 
weakness of the abdominal wall. 

Well-arranged pads applied by means of a belt must be employed to 
prevent protrusion, or probably in some cases it would be justifiable to cut 
down upon and stitch together the margins of the aperture, an operation 
not of a very serious nature, and not of course necessitating any injury to the 
peritoneum. 

Umbilical Hernia. — Umbilical hernia in children may be congenital or 
acquired : in the congenital form it is sometimes due to persistence of the foetal 
condition where a coil of bowel lies outside the abdomen ; in other cases, 
as already pointed out, it is the result of failure of closure of the ventral 
laminae. 

The acquired form usually appears within the first few months of life ; in 
this case the rupture protrudes not through the centre of the scar, which is 
occupied by the fibrous remains of the vessels, but usually above it or even 
through an independent opening in the linea alba. Astley. however, believes 
that the protrusion is generally through the ring. Both forms of hernia are 
readily reducible and usually consist of small intestine ; the amount of 
protrusion varies from a mere convexity of the navel to a prominent glove- 
finger-like outgrowth. 

The treatment consists in applying a flat pad of wood or poroplastic felt 
about the size of a penny and two or three times as thick : this pad should 
be covered with flannel and fixed over the umbilicus by a broad band of 
strapping encircling the body or by a soft webbing belt ; we prefer the 
former as more efficient and less likely to slip, though it is not so comfort- 
able as the belt. If the pad is worn constantly for from one to three months, 
according to the age of the child, the hernia is usually * radically cured.'" In 

1 Vide Diseases of the Navel — Umbilical Polypus. 



156 Diseases of the Digestive System 

cases which obstinately resist treatment the orifice should be cut down upon 
and sutured. A case of irreducible umbilical hernia containing omentum 
was successfully operated on by Roocroft in a girl of 14 years ; ' but it is 
clear that most cases of umbilical hernia in children are cured, since the 
condition is hardly ever seen in young adults. We have had occasion to close 
by operation a median ventral hernia in a child. The result was successful. 
inguinal Hernia. — Inguinal hernia is met with in childhood in the 
following varieties : 

1. The funicular process of peritoneum remains widely open and in free 
communication with the cavity both of the peritoneum and tunica vaginalis : 
a hernia descending into this cavity is a true congenital hernia, or hernia of 
the tunica vaginalis (Teale). 

2. The tunica vaginalis may be shut off from the funicular process at the 
upper part of the testicle ; a hernia coming down into the patent process is 
called a funicular hernia, or hernia into the funicular process. 

3. When the same condition as in (2) exists, but the hernia instead of de- 
scending along the canal of the funicular process pushes down a separate 
pouch of peritoneum behind the process, the hernia is called infantile or 
encysted. The same name is given to cases where the funicular process is 
obliterated at the internal ring or just above the testicle, and the septum 
is pushed down and invaginated into the lower part of the process. In the 
former case, in cutting down upon the bowel from the front three layers of 
peritoneum, viz. two funicular and one sac proper, will be found in front of 
the gut ; in the second case two layers will overlie the bowel. 

4. An ordinary acquired hernia may be met with. Hernia may, of course, 
be complete or incomplete — that is, it may descend into the scrotum or only 
distend the canal or bulge at the internal ring. 

The first and second forms are much the commonest, and it is usually 
impossible to be certain which is present unless the parts are exposed by 
operation. Where the testicle is completely wrapped round by the hernia 
it is probably congenital ; where the testicle remains a distinct boss upon the 
surface of the hernia it may be funicular, though it is not by any means 
always so. We believe the funicular variety is the more frequent. Infantile 
or encysted hernia can only be recognised by operation, but it may be sus- 
pected if, after reduction of a hernia, an unusual amount of thickening along 
the cord remains, or if there is a hydrocele of the cord or an infantile hydro- 
cele in conjunction with a reducible hernia. Fortunately, an exact diagnosis 
of these conditions from one another is not of much importance. 

Hernia may develop at any age ; it is sometimes noticed immediately after 
birth ; in other instances it comes down later when, from failure of health, or 
bronchitis, or whooping cough, the muscular walls of the abdomen become 
relaxed, and are in addition overstrained by coughing, violent crying, strain- 
ing in defalcation, micturition, &c. So common is it for straining in micturi- 
tion to bring down a hernia, that it is quite certain that phimosis is a most 
fertile cause of rupture. 2 The presence of a calculus or worms acts in the 
same way. Hernia very commonly accompanies ectopia vesicae. 

1 Lancet, August 2, 1884. 

2 An important fact first pointed out by Mr. J. A. Kempe. 



Inguinal Hernia i 5 7 

As is well known, inguinal hernia is sometimes met with in female chil- 
dren, though not nearly so commonly as in boys. Of 112 unselected cases 
of hernia seen in our out-patient department, there were — 

In males . 57 right inguinal, 12 left inguinal, 16 double, and 9 umbilical. 
In females 4 „ „ 5 „ „ • no „ „ 9 (? 10) „ 

Mr. Leader Williams tells us that in his experience m the Maternity Depart- 
ment of St. Mary's Hospital, Manchester, umbilical hernia is by far the 
•commonest variety, and this is no doubt true of the first few weeks in life. 

Most commonly an inguinal rupture in a child contains small intestine 
■with or without omentum, perhaps most commonly without. Other parts of 
the intestinal canal are, however, not rarely found. We have many times 
during operation found the caecum and vermiform appendix in a hernia, and 
not rarely the appendix can be very distinctly felt through the coverings 
without an operation. 1 The ovaries in girls and the bladder in either sex are 
sometimes protruded. 

Generally a rupture is easily reducible, but often it is necessary to make 
the child lie down before it readily goes back ; it then often does so sponta- 
neously. Violent crying will sometimes make it quite impossible to safely 
reduce a hernia, and the child must be quieted or anaesthetised before 
reduction. 

It must be remembered that, though as a rule herniae are opaque, a 
tightly distended rupture consisting only of bowel, and that full of flatus, in 
a thin-skinned child will be distinctly translucent ; this fact was, we believe, 
first pointed out by Mr. Howse, and we have several times seen it. 

Various abnormal conditions may complicate hernia ; thus the testis may 
"be entirely retained or have imperfectly descended on the same side. A 
vaginal hydrocele or hydrocele of the cord may coexist with a hernia, or fluid 
as in a congenital hydrocele may distend the sac of a congenital hernia. The 
rupture, of course, may be single or double, and sometimes of a different 
species on the two sides. We have seen a ' funicular ' and a ' congenital ' 
hernia on opposite sides in the same child. Children the subject of hernia 
are undoubtedly often affected with intestinal disturbance, which appears to 
be sometimes at least due to the hernia. It has, however, been suggested 
by Lane that thelhernia is due to the intestinal trouble, and it is undoubtedly 
true that marasmic children with chronic indigestion and irregular and often 
constipated bowels not uncommonly have hernias which are not readily cured 
till the nutrition is improved. 

Ruptures in children are occasionally irreducible ; when this is due simply 
to straining, as already pointed out, the difficulty is easily got over, in other 
cases the hernia may be obstructed by its contents as in adults ; again, 
adhesions to the sac or to the testicle or matting together of bowel to 
bowel, or bowel to omentum, may prevent reduction. In one of our cases a 
large hernia was made irreducible by the presence of tuberculous mesenteric 
glands which had evidently enlarged after their descent, and it was only 
after removal of some of these and enlargement of the rings that the rupture 

1 Vide papers in the Brit. Med. Jour. vol. i. 1887, by Mr. F. Treves, and also by one 
of the present writers. 



i 5 S Diseases of the Digestive System 

could be reduced ; the child recovered, but evidence of tuberculosis, of 
course, remained. 

It is somewhat rare for a hernia to become strangulated in childhood. 
We have, however, met with several such cases ; they differ in no respect 
from the similar condition in the adult, but considering the extreme tender- 
ness of the tissues in children immediate operation is the wisest course in 
preference to treatment by ice, or more than gentle and momentary taxis ; 
we have known a child die of the injury done to a coil of intestine which 
was reduced before the child was seen by us, and could only have been 
strangulated for a few hours. The youngest cases with which we are 
acquainted were one of three weeks by Halsewood, 1 and another successful 
One of our own, and one of four weeks by Maunder. The sac always 
requires opening, since the neck itself forms the constricting part. Some- 
times in an hour-glass sac the constriction may be in the scrotum. 

The treatment of hernia in children resolves itself into three questions - 
first, the removal of all causes tending to produce rupture, such as cough, 
phimosis, &c. ; secondly, treatment by apparatus ; and lastly, operations. 

Ruptures in children sometimes get well of themselves without treatment, 
or simply by keeping the child lying down and avoiding disturbance of its 
temper and bowels. In other instances circumcision will prevent further 
descent of hernia by removing the source of straining. 

Failing these means, the wisest plan is at once to provide a well-fitting 
truss, a matter which should be seen to by the surgeon himself, and not left 
to an instrument maker. The truss must be worn night and day without any 
intermission, never being removed on any account for washing or any other 
purpose except to put another on ; this is necessary, because the truss is in 
children used to cure rupture, and not merely to palliate it as in adults. When 
it is absolutely necessary to change a truss, the new one must be got ready, 
the finger slipped beneath the old one to keep pressure upon the canal and 
then the truss changed, the child being kept on its back and soothed to pre- 
vent crying. During the treatment the skin must be carefully watched and 
kept dry and unirritated by the free use of boric acid powder ; this can be 
dusted beneath the truss without removing it. A little judicious packing with 
absorbent wool will serve to take pressure off any tender part. Almost any 
hernia during the first year of life that can be kept up without once coming 
down for three months will be permanently cured ; after the first year a 
longer time is required. 

The ordinary flat- pad trusses do very well if the parents can afford to fre- 
quently renew them, but they get stiff and hard, and the springs soon rust 
and rot with the frequent soakage of urine, so that they have to be frequently 
changed, and a duplicate should always be at hand in case of sudden giving 
way. One descent of hernia undoes all the preceding treatment ; this is the 
cardinal rule to impress upon the mother or nurse. The inflatable and the 
glycerine pad rubber trusses we have found useful and satisfactory when 
carefully managed, and they are not affected by urine nearly so rapidly as the 
common truss, but they require careful inspection from the first, as they are 
often imperfectly made, and flaws or tears are soon fatal to them. The hard 

1 Lancet, Dec. 1884. 



Inguinal Hernia 159 

rubber truss is sometimes spoken well of ; we have not tried it. Celluloid or 
gum trusses are good. If from bad management a sore is produced by truss 
pressure, careful padding will often avoid the necessity of leaving off the 
truss ; but with proper attention and care that the truss spring is not too 
strong, it seldom occurs. 

Hydrocele and orchitis we have more than once seen as the result of 
wearing a truss ; in such cases we may be sure that the spring is too strong, 
and a different truss must be applied. Spica bandages, wool trusses, &c. 
are inefficient substitutes for a good truss. The pad of the truss should be 
flat and not convex, and peaked trusses are never required : the object is to 
prevent the hernia from entering the canal, not merely to cover up the 
rupture. 

When a fair trial has been given to trusses, different ones being, if 
necessary, employed, and all sources of irritation have been removed and 
still the rupture cannot be kept up, an operation for its permanent cure 
should be performed ; it is of course required in only a small percentage of 
cases. 

Of all the various plans, the one we think simplest and as good as any, 
and the only one we shall describe, consists in making a free incision over 
the canal and upper part of the scrotum, cutting down to the sac, reducing the 
hernia, closing the neck of the sac and passing silk sutures through the walls 
of the canal. To do this the sac must be opened and the finger passed into 
the abdomen to make sure that the canal is clear and to guide the needle. 
The needle, which must be in a handle, is passed through one side of the 
canal, and guided by the finger is brought out at the ring ; it is threaded 
with silk and withdrawn, then unthreaded and passed through the other side, 
then threaded with the other end of the same silk and again withdrawn ; two 
or three sutures are passed in this way till it is felt that there are enough to 
close the canal, the threads are then tied. One edge of the sac close up to 
the threads is then picked up and threaded upon the needle, and successive 
portions of the surface of the sac are pinched up and transfixed (like thread- 
ing them upon a skewer) until the other edge is reached ; the needle is then 
threaded with catgut or silk and withdrawn, leaving the ligature, which when 
tied puckers up the sac into closely applied folds which soon adhere, and the 
sac is thoroughly obliterated ; by this means all trouble and disturbance in 
separating the sac from the cord is avoided, and the closure is quite firm and 
complete. Sometimes we ligature the sac before closing the canal : this is 
not quite so easy, and it is not a matter of importance. The wound should 
be closed, and will heal by primary union. The silk requires careful pre- 
paration ; if not thoroughly sterilised, a troublesome sinus is likely to form, 
and the suture finally comes away. We prefer to select the particular mode 
of operation most suited to the case, rather than to confine ourselves to any 
one method exclusively. There is sometimes a great deal of swelling after 
the operation, but this gradually subsides and should be looked upon as a 
good sign of firm consolidation. For the methods of managing complications 
of the operation we must refer to the ordinary text-books, for undescended 
testis to the chapter on that subject. An omental sac may be met with ; we 
have seen a very perfect instance. The management of such cases and of 
adhesions differs in no way in the child from that of similar conditions in the 



160 Diseases of the Digestive System 

adult. It is better not to allow a truss to be worn after the operation unless 
there is some special reason for it. 

The operation is not free from risk and not always successful ; we have 
had one death from peritonitis coming on some time after the operation, and 
have had to operate more than once in several cases. In the fatal case the 
canal was perfectly closed and the peritoneal surface almost undimpled. 
The cause of failure is chiefly a thin and flaccid condition of the abdominal 
muscles, which cannot be made to form a firm barrier. 

Femoral hernia in children is very rare, we have never seen a case ; one 
recorded by Sabourin in a premature female infant was readily cured by a 
truss. E. Owen saw one in a boy of 10 years out of 748 cases of femoral 
hernia. 1 Diaphragmatic hernia is occasionally met with. 

Prolapsus Recti. — Slight degrees of prolapse of the rectum are common 
in children and are often only transitory, occurring perhaps once or twice and 
not again ; the more severe forms are much rarer. 

Prolapse of the rectum consists in protrusion of more or less of the 
rectal wall through the anus. The slight and most common form is simply 
a pushing out of a ring of mucous membrane, which is readily reducible and 
often only comes down when the child strains. In other cases the whole of 
the rectal coats from mucous membrane to peritoneum may be protruded. 

The first variety of prolapse is usually about half an inch long and appears 
as a red mucous ring with radiating folds diverging from the central orifice ; 
the mucous and cutaneous surfaces shade off into one another at the margin of 
the protrusion. The second form is larger, reaching from one to two inches 
in length, and is often conical in shape, its base being at the anus ; the folds 
are not radial but annular, running round the prolapsed part ; the orifice is 
central, and on passing the finger into it, it is evident that the whole thickness 
of the bowel, and not merely mucous membrane, is involved in the prolapse. 
Sometimes this form of protrusion reaches much larger dimensions, even six 
inches in length, and in such cases necessarily a large pouch of peritoneum 
is carried down, and this is more extensive on the anterior than the posterior 
aspect of the bowel. In one case that we examined post mortem there was 
a definite diverticular pouch with a sharp lunated edge projecting from the 
recto-vesical hollow down the anterior wall of the rectum ; it seemed to 
us probable that the presence of a coil of bowel in this pouch would have 
much to do with keeping down the prolapse. 2 Not only small intestine but 
the ovaries even may be found in this peritoneal pouch, which then becomes 
the sac of a rectal hernia ; the characteristic gurgling or the presence of a 
solid body felt on manipulating the walr-of the protrusion may give a clue to 
the extent of the disease. Rectal hernia sometimes comes down behind 
the bowel, or may even protrude through a gap in the muscular coats. 
(Kelsey.) This variety of prolapse is sometimes curved as a result of 
traction by the mesocolic fold of peritoneum or the attachment of the rectum 
to the vagina. (Van Buren.) In it also the mucous and cutaneous surfaces 
shade off into one another, though the transverse folds of mucous membrane 
on the surface of the prolapse may somewhat obscure the line of junction. 

1 Lancet, June 6, 1884. 

2 The specimen from this case is in the Owens College Museum ; this definite pouching 
is, so far as we know, undescribed hitherto. 



Prolapsus Recti 161 

A so-called third form of prolapsus recti, where the upper part of the 
rectum or the sigmoid flexure is invaginated into the bowel below and pro- 
trudes from the anus, is recognised by its size and by the presence of a sulcus 
between the prolapse and the anal margin. This condition, however, is more 
naturally considered as an intussusception than as a prolapse. 

The mucous surface of the protruded gut may be nearly natural, but more 
often is excoriated and coated over with a thick slimy mucus ; it sometimes 
becomes congested and may even slough from irritation or constriction by 
the sphincter, though in most cases the anus is so lax and patulous that the 
existence of a sphincter at all is hardly felt by a finger passed within the 
opening. Bleeding to small amounts often occurs, and there is much mucous 
discharge. 

The motions come away freely, but the irritation and discharge weaken 
the child, and he loses flesh and health. In most cases the prolapse is re- 
ducible with more or less difficulty, but often it returns immediately pressure 
is taken off; in others it remains up until the child strains from any cause and 
then redescends ; in others again the protrusion after a time becomes irre- 
ducible from matting together of the parts and from congestion. 

Where a rectal hernia exists it is subject to all the conditions of an 
ordinary inguinal hernia, i.e. it may be reducible or strangulated, &C. 1 Occa- 
sionally the prolapse sloughs and faecal fistula results, or the wall may burst 
in attempts at reduction. 

The causes of prolapsus recti are many, though it is obvious that there 
must be some weakness of the sphincter and levator ani or relaxation of the 
rectal walls in these cases, or prolapse would be much more frequent than it is. 
Any condition that produces violent and constant straining may bring on 
prolapse in a child predisposed to it. The child is generally miserable and 
weakly when seen, but this is no doubt partly the result of the irritation. 
Phimosis, contracted meatus urmarius, stone in the bladder, cystitis, con- 
stipation, diarrhoea, worms, polypus recti, violent coughing, &c. all may cause 
prolapse. Boeckel believes stricture of the rectum to be a cause, and in 
one case we found a tight annular stricture of the rectum about one inch 
from the anus ; this only admitted the tip of the index finger in a child of 
about three years old ; the stricture apparently formed the apex of the 
prolapse, and may possibly have been the result rather than a cause of the 
protrusion. 

The diag?iosis of prolapsus recti is easy where the protrusion is large : the 
only doubtful point is what extent of rectal wall is included in it. If small 
it can only be mistaken for piles or polypus ; the former are exceedingly rare 
in children and never form a complete ring", the latter is of course a single 
isolated, usually pedunculated swelling ; a mistake can only occur from lack 
of examination. Kelsey lays it down that any prolapse over 2^ inches in 
length contains peritoneum, while the presence of a sulcus serves to dis- 
tinguish between the second form and the rectal intussusception. The 
direction of the folds and the size distinguish between the first and second 
varieties. » 

The treatment of prolapse consists first in removing the cause of strain- 
ing, next the child should be kept rigidly lying down in bed ; the protrusion 

1 Vide Kelsey, in an elaborate paper in Archives of Pediatrics, 1885. 

M 



1 62 Diseases of the Digestive System 

must be reduced each time it comes down, and if it constantly recurs an 
attempt should be made to keep it up by a pad and T-bandage, or by 
strapping the buttocks tog-ether with a broad piece of plaster. The bowels 
should be kept easily open so as to avoid straining, and it is sometimes 
useful to support the sides of the anus during defalcation by pressure or by 
drawing the skin tightly to one side ; as advised by Van Buren, the 
motions should be passed into a napkin without the child being allowed to 
sit up. 

Enemata of cold water or astringents, tannin, quassia (2-4 oz. of the 
infusion), oak bark, sulphate of iron, &c, will do good in many cases, and it 
is only the more severe forms that are not cured by bed and the means 
above described ; indeed, simple confinement to bed cures the majority of 
these children. Should the prolapse be irreducible, an anaesthetic should 
be given : if this fails and there are no urgent symptoms, a warm fomentation 
and putting the child, if old enough, upon his hands and knees with the pelvis 
raised, will sometimes succeed. 

If sloughing occurs the prolapse may be protected from irritation, and 
dusted over with boric or salicylic acid, and kept clean. The sloughing 
will very likely cure the prolapse, but it may be at the expense of causing 
a stricture, and this, if it is at the apex of a long prolapse, will be high up 
in the rectum when the protrusion is reduced. 

Failing milder measures, the actual cautery should be employed, four or 
five narrow lines being drawn in the long axis of the gut from skin margin 
to near the apex. 

Paquelin's cautery is the most useful instrument, and is better than 
nitric acid or nitrate of silver. Only the mucous membrane of the prolapse 
should be burnt through, while at the skin margin the cautery should lay 
bare the sphincter ; sufficient irritation must be produced to procure adhe- 
sions between the mucous and muscular coats. Bryant advises the applica- 
tion of nitrate of silver over the whole surface. After the application the 
bowel should be reduced and a pad applied. Another useful plan is to 
excise wedge-shaped strips from the margins of the anus, including a little 
of the mucous membrane, the base of the wedge being at the anus ; the 
edges of the wounds are then brought together, and the resulting contraction 
supports the bowel. We have found this successful in a very severe case. 
In severe and irreducible cases the prolapse has been clamped and removed, 
but this should only be done as a last resource and with the full knowledge 
that in a large prolapse the peritoneum will probably be opened, and the 
utmost care must be taken to reduce any rectal hernia that may exist. If the 
peritoneum is wounded it must be carefully closed with catgut sutures. This 
operation is rarely justifiable ; we have once done it but unsuccessfully : it is 
not to be confounded with the method of treating prolapse by removal of strips 
of mucous membrane in the long axis of the gut by means of the clamp, a 
method sometimes employed. 1 

The bowels should be open two days after operation, as delay makes the 
first action very painful. 

1 Dr. Cullingworth related at the Pathological Society of Manchester, December 1887, 
a successful case of complete excision of a large prolapse in a young lady in which the 
peritoneum was opened. 



Fistula in Ano — Condylomata — Rectal Polypus 163 

Fistula in Ano is an uncommon condition in children, though we have 
several times met with it. As in adults, it is apt to be associated with 
tuberculosis. As pointed out by Mr. Holmes, most of the fistulas are blind 
external ones ; this is also our experience. There is nothing peculiar in 
either the pathology or treatment, which is the same in children as in 
adults. 

We have, however, introduced the plan of dividing the sphincter ani 
subcutaneously close to its attachment to the tip of the coccyx, and then 
scraping out the fistula. This is a less severe way of dealing with fistulas 
than the ordinary plan, and is probably sufficient for all cases likely to be 
met with in children. 

An ischio-reGtal abscess may discharge per vaginam, as in a case under 
our care at the Children's Hospital in 1896. 

Piles in children are usually described as unknown, or almost so, and 
their occurrence is no doubt very rare ; we have, however, seen two cases of 
external piles, and Ogston, jun., has recorded a case in a child 3 days old. 
In another instance a child was brought to us for bleeding from the bowel, 
and on examination a condition indistinguishable from that of well-developed 
internal and external piles was found ; this had been giving trouble since the 
child was about a year and a half old, but the affection was probably congenital. 
Light was thrown upon the case by the presence of a large partially 
degenerated naevus on the buttock, quite distinct, and at a distance from 
the anus, and probably the case was really one of nasvus of the anus. The 
disease was readily cured by applying ligatures just as for piles. There was 
no nasvoid tissue higher up, though this is occasionally met with. Ligature 
or the actual cautery is the best treatment. Howard Marsh and Barker 
have recorded instances : in one the patient, an adult, ultimately died of 
haemorrhage. 

Condylomata frequently occur in children about the anus or its neigh- 
bourhood as fiat, sessile, pink or pinkish-white elevations, or sometimes as 
large irregular masses. They are usually a manifestation of congenital syphi- 
lis, but sometimes, we believe, simply the result of dirt and irritation. When 
syphilitic the local treatment is, of course, subordinate to the general measures, 
but dusting over with calomel or the application of black wash usually speedily 
cures them. Sometimes, especially if non- syphilitic, they are more obstinate, 
and may require to be scraped away or treated with the actual cautery, nitrate 
of silver, or chromic acid. 

Polypus of the Rectum is one of the diseases which, though not abso- 
lutely peculiar to children, are by far most commonly found in them. Most 
cases of rectal bleeding in children, apart from that due to mere tenesmus 
and diarrhoea, are due to polypus ; hence careful search should be made for 
a tumour in all cases where unaltered blood escapes from the bowel. 

Rectal polypi are usually pedunculated rounded bodies about the size of a 
hazel nut : they are composed of myxo-fibromatous or soft fibro-cellular tissue, 
or in some cases are adenomata ; in the former the surface is smooth, 
though sometimes superficially ulcerated or excoriated, and the pedicle is 
often long and thin, though the growth in its early stages may be sessile. 
Adenomata are granular or warty in appearance. The anterior wall of the 
rectum about an inch from the anus is the usual seat of these growths ; some- 

M 2 



164 /diseases of the Digestive System 

times, however, they are attached higher up in the bowel, and may be even 
beyond reach of the finger. 

Polypi, besides the loss of blood, give rise to irritation and tenesmus, 
together with mucous discharge from the gut, and frequently to prolapse. 
The growth itself is often protruded from the anus during straining, and is 
sometimes mistaken for prolapse or piles ; examination, however, readily 
enables a diagnosis to be made, as the polypus is quite separate from the 
general mucous surface. The pedunculated form is best treated by simple 
twisting off, or a ligature maybe applied to the pedicle, which is then snipped 
through with scissors ; to do this conveniently the child should be anaesthe- 
tised, and the rectum well dilated and a speculum used; often during an 
examination the pedicle is torn through and the polypus comes away without 
further trouble, and occasionally the mass is detached during defalcation and 
passes with the motion. The sessile form may be ligatured or snipped off 
and its base cauterised. Recurrence of the growth is improbable. 

We have met with rectal polypus in two members of one family, and 
Cripps relates similar cases. 

Occasionally the whole mucous surface of the lower bowel is the seat of 
warty adenomatous growths, as in a remarkable case recorded by our 
colleague Mr. Whitehead. Dermoid cysts have also been found. We have 
had occasion to remove a suppurating dermoid cyst from the ischio-rectal 
fossa of an adult. Before operation it was thought to be a simple abscess. 

Small superficial ulcers and fissures about the anus are common in dirty 
and in syphilitic children, but they are more common at a little distance from 
the orifice than actually at the anus. They give rise to pruritus, but seldom 
to the severe symptoms seen in adults ; sometimes there is reflex irritation 
of the urinary organs, frequent micturition, &c. In the non-syphilitic cases, 
cleanliness, the destruction of worms or other irritants, and the application of 
nitrate of silver are usually sufficient. Menthol has been recommended for 
the pruritus. Tuberculous ulcers may be met with. Ischio-rectal abscess is 
not very uncommon, and should be opened early ; it is probably better to 
divide the external sphincter at the time to avoid the risk of tedious healing 
or the formation of a fistula. 

Rectal ulcers are due to either follicular inflammation, in which the 
rectum is involved in common with the rest of the lower gut, or to rectal 
catarrh or the presence of a polypus. The symptoms are seldom marked, 
and the condition is consequently not often seen ; vide also PROLAPSE and 
Dysentery. 

Removal of irritation and improvement of the general condition of the 
intestinal mucous membrane are the only treatment required. 



i6 5 



CHAPTER IX 

DISEASES OF THE DIGESTIVE SYSTEM — {continued) 

Malformations and Deformities of the Digestive System 

Hare-lip. — The upper lip is developed from the fronto-nasal process and 
the maxillary processes which in the normal course of development fuse in 
front of the mandibular fissure. Should this fusion fail to take place on 




Fig. 22. — Shows the lines of union of the face, and indicates the origin of the chief malforma- 
tions, af, af', situations of congenital auricular fistulae. I., II., III., IV., indicate the 
external orifices of brancliial fistula;. I. is the external auditory meatus ; OF, the orbital 
fissure ; mf, the mandibular fissure ; hh', the lines of lateral hare-lip ; cf, cf', mark the 
situations of congenital cei-zncal fistulae. (From Bland Sutton, Lancet, Feb. i, 1888.) 

either or both sides, a single or double hare-lip respectively results. If 
the inward growth of the palatine processes which should take place to 
separate the nasal and buccal cavities fails, cleft palate occurs. 



1 66 



Diseases of the Digestive System 



The praemaxillae arc formed from the globular processes forming the 
angles of the fronto-nasal process; hence, should the lateral process not fuse 
with the globular, a cleft between the praemaxilla and the maxilla will 
result on that size, while, if there is suppression of the two globular pro- 
cesses and septum, median hare-lip follows ; this, though exceedingly rare in 
man, is met with more or less constantly in some mammals in which the 
globular processes fail to unite with one another. 1 

As to the actual causes of such arrest of development much controversy 
exists. It is commonly asserted that frights and shocks of various kinds, as 
well as strong maternal impressions of other sorts occurring about the 
time of the development of these parts, may determine the arrest of growth 
which results in such malformations. Although many instances have been 
brought forward to show a causal relation between the two facts, it is not 
clearly established that anything more than a coincidence really exists. 

It is, however, certain that in many cases there is an hereditary tendency 
to such defects, and it is also certain that they are often associated with other 

congenital malformations. It is asserted 
that the hereditary tendency is commonly 
transmitted on the father's side. 

Various degrees of hare-lip are found ; 
Mr. Lucas believes that congenital absence 
of an upper lateral incisor is sometimes 
the forerunner of hare-lip and cleft palate 
in a later generation ; in some instances 
there is merely a deficiency of the mus- 
cular fibres of the orbicularis, so that 
although the lip is not actually fissured 
there is a furrow from the absence of 
muscle and the consequent thinning of the 
lip which at the affected part consists only 
of skin and mucous membrane, often some- 
what imperfect in structure, together with 
an intervening layer of connective tissue. 
In other cases there is a shallow notch 
in the prolabium or at the anterior nasal 
orifice, the parts being otherwise well 
formed. Between these conditions and 
the most severe forms of hare-lip all degrees of deformity may exist (figs. 
23 and 24). 

As the superficial structures are developed more or less independently of 
the bony framework of the face, hare-lip may occur without any cleft of the 
palate, and without any separation of the praemaxilla from the maxilla. Most 
commonly, however, if the hare-lip is complete, i.e. if it extends into the 
nostril on one or both sides, there is also deformity of the bones, either non- 
union of the praemaxilla or single or double cleft palate. Thus there may 
be a mere notch in the line of the gum, a cleft through the alveolar margin 
on one side, a cleft running backwards, on one side of the nasal septum 
through the hard and soft palates, or a double cleft isolating the praemaxilla 
1 Vide Bland Sutton, Lancet, February 18, 1888. 




Fig. 23. — A simple case of Double incom- 
plete Hare-lip. This is much rarer than 
the complete variety. 



Hare- 



167 



from the maxillae and leaving" it protruding from the end of the nasal septum 
while the two halves of the hard and soft palate are completely separated and 
the nasal septum is seen in the middle line as a prominent ridge not attached 
to either side of the palate — complete or double-cleft palate — the septum is 
often seen to taper off and end as a ridge upon the upper wall of the pharynx. 
It is usually said that cleft palate is always single, but the term may well be 
limited to those cases where the septum is attached to one palate process 
only. In other instances the failure of union may occur only in the soft 
palate, more often in the soft with just the posterior edge of the hard palate, 
or in slighter degrees of the deformity still the uvula alone may be bifid, or 
the palate perforated. Most rare of all is cleft of the hard without cleft of 
the soft palate. We have once or twice seen this condition, which is apt to 
be mistaken for a congenital syphilitic or other lesion. In some recorded 
cases the uvula has been absent. 

Two other conditions associated with hare-lip and cleft palate respectively 
are of extreme importance as regards successful operation ; the one is the 
flat, wide, distorted ala of 
the nose found in complete 
hare-lip ; the other is the 
pitch of the palate arch, 
which may be either wide 
and flat or very high and 
narrow ; the latter condi- 
tion is said to be often 
associated with mental 
deficiency. 

Sometimes the prae- 
maxilla carries the four 
incisor teeth, and these 
are therefore implanted in 
the projecting mass in 
cases of complete double 
hare-lip. In some in- 
stances, however, one in- 
cisor tooth is attached to the maxilla, most commonly the outer tooth is 
suppressed altogether, its sac having apparently been lost in the cleft. 

Rotatioii of PrcEinaxilla. — Very frequently there is some rotation of 
the praemaxilla upon a vertical axis, especially in unilateral cleft ; in such 
cases the teeth are also rotated and may be so directed that the outer border, 
or in some instances the cutting edge, looks directly forwards. This position 
of the teeth requires to be remedied after their complete eruption. As, how- 
ever, hare-lip is now usually operated upon before the teeth are cut, their 
exact position is in such cases of little importance at the time. 

Feeble Vitality. — The deformity of simple hare-lip unaccompanied by 
malformation of the palate is important almost solely on account of the 
disfigurement, though it must be borne in mind that many of these children 
have other deformities or are weakly, and, though without any actual malforma- 
tion, do not seem to have sufficient vitality to make it possible to rear them. 

When, however, the failure of the union affects the palate as well as the lip, 




24. — Severe Double Hare-lip. Showing the projecting 
praemaxilla. 



1 68 Diseases of the Digestive System 

other ill results follow ; the child is unable to suck from inability to produce 
a vacuum in the mouth ; its nasal passages and pharynx are exposed to the 
air and become affected with chronic catarrh, its tongue is dry and the air 
entering its lungs is imperfectly warmed. Even when fed with a spoon the 
food often regurgitates through the nose. Hence to the already weakly con- 
dition of the child are added the dangers of insufficient nutrition and catarrh 
of the respiratory tract. It is not, therefore, to be wondered at that only a 
small proportion of children so affected survive ; should they do so, they are 
subject to the further drawback of imperfect and indistinct speech. It is 
alleged that many of these children die from starvation, which might be 
prevented by operation : we do not think this is true ; we believe they would 
die in any case from simple lack of vitality. 

In those cases where the child is unable to suck, it should be fed in an 
upright posture, when the milk is less likely to regurgitate through the nose, 
or one of the special obturator teats devised by Mr. Mason and others em- 
ployed ; probably the best of these is Oakley Coles' rubber teat. 

The treatmeitt of hare-lip is necessarily purely operative ; several impor- 
tant questions have, however, to be considered in each individual case. First, 
it is clearly of no use to operate on an infant that is incapable of living from 
the presence of some other deformity incompatible with life, nor in cases 
where the general health of the child is feeble and it is losing weight, since 
union of the wound would not take place. No operation then should be done 
unless the child is in perfect health, and the time of actually cutting a tooth 
should be avoided. 

Age for operation. — Next comes the question of the best age for operation. 
On the one hand it must be borne in mind that there is a certain amount of 
risk attending the necessary loss of blood and the shock in a very young infant, 
and on the other hand that, if the deformity is severe, the effect of closing 
the cleft in the lip as regards moulding the subjacent parts into their natural 
shape will be greater the younger the child and the softer the tissues. As has 
been well shown by Dr. Rawdon, of Liverpool, and others, a most remarkable 
modelling process in the outline of the upper jaw takes place after closure of 
a hare-lip, and more than this, the width of the cleft in a divided palate is 
much reduced after a time by uniting the lip. 

Increased facility in feeding and the removal of a hideous deformity are 
other reasons for early interference, while experience shows that early opera- 
tion is not attended with a specially high rate of mortality. Many infants die 
shortly after the operation for hare-lip, but in most of these death is due to 
malnutrition, not to the operation. 

The common practice now is to operate at any time after the first three 
weeks of life in the less severe cases and a month or two later in the more 
serious deformities, double hare-lip being dealt with later still ; operations 
are, however, often successfully done within the first few 7 days of life. Our 
own preference is not to operate before a month in single hare-lip, nor before 
six months in severe deformity. 

Operation. — It is, in our opinion, much better in all cases to give chloro- 
form for the operation. The coronary arteries should then be controlled by 
bulldog forceps or finger pressure, and the lip very freely detached from the 
maxilla, the dissection being carried far outwards along the jaw, upwards 



Hare-lip i6g 

nearly to the lower margin of the orbit, and inwards and upwards so as to 
freely detach the alae nasi from the subjacent bone. 

The extent of the separation will, of course, depend upon the severity of 
the case ; but, as a rule, failure is more often due to insufficient separation 
than to any other single cause. 

The bleeding during this part of the operation is often free, but is easily 
controlled by pressure, and stops immediately after the stitches are put in ; 
for this reason we sometimes pare the edges of the cleft before freeing the 
lip, though if the paring is done last it is easier to adjust the edges exactly. 
It is very important to slice away the sides of the cleft freely, and not merely 
to scrape them or to take away a thin shaving ; too little is much more often 
taken away than too much. 

In adjusting the edges of the wound, the chief points to attend to are that 
the prolabial margin on one side exactly corresponds with that on the other ; 
secondly, that the highest suture is well within the nostril, so as to prevent a 
gap at the upper margin, and to remedy the tendency to flattening of the 
nostril ; thirdly, to insert a suture on the inner and under (mucous) surface 
of the lip ; this more than anything else prevents the appearance of an un- 
sightly notch at the lower end of the line of union. The main sutures should 
be made to include the whole thickness of the lip except the mucous mem- 
brane ; the intermediate ones may be only superficial. 

Silver wire sutures, usually about three in number, with intervening horse- 
hair stitches, will be found very successful, and are, we think, on the whole, 
the best. 

Hare-lip pins are hardly ever necessary, and should not be used if it is 
possible to avoid it. We have not used them for years. If the lip is freely 
separated from the upper jaw, there will be no tension. We used sometimes 
to put pins in temporarily to keep the parts in apposition while the rest of the 
stitches are being inserted, and then remove them at the end of the opera- 
tion. If the pins are left in, it should be for not longer than forty-eight hours ; 
the rest of the stitches may be taken out a day or so later, according to the 
amount of irritation set up and the condition of the child. Where the power 
of repair is feeble, the sutures should be left in longer. Some surgeons pre- 
fer silk or gut sutures. The first stitch, if pins are not used, should be put 
in opposite the prolabial margin ; this answers the double purpose of con- 
trolling the coronary arteries and of fixing the level of adjustment of the two 
sides. If forceps have been used for controlling the bleeding, they should be 
removed just before putting in the stitches. 

Some surgeons apply a strip of strapping over the lip after the operation, 
or use a Hainsby's truss ; neither is necessary. We prefer to dust the wound 
over with boric powder and leave it exposed. The strapping is objectionable 
in that it tends to collect blood and mucous discharge from the nostril, and 
so to irritate the wound. It is. however, sometimes wise to put plaster on 
for forty-eight hours after removing the sutures until the union is quite firm 
and it is a good plan to lay a narrow strip of lint over the line of union 
beneath the plaster. 

If the child has not been weaned before the operation, it should be 
allowed to suck as soon as it recovers from the chloroform ; in such case 
care must be taken to prevent injury to the mother's breast from the wire 



1 70 Diseases of the Digestive System 

sutures. In most cases, however, the child has been bottle or spoon 
fed. 

I n any case the hands must be carefully secured by bandaging them to the 
chest with a flannel bandage or by some similar means, and watch kept that 
no injury is done to the lip. 

The principal methods of operating for single hare-lip arc as follow : 
each case must be managed according to its special needs, no one method 
answering in all cases : 

1. The edges of the fissure are simply pared by a straight incision and 
brought together. This, though answering well in some cases, is apt to leave 
a notch at the prolabial margin unless there is abundance of material to work 
with. By making the line of incision slightly curved, with the concavity 
towards the cleft, the notching may often be avoided (fig. 25 e,f). 

2. The single flap method shown in fig. 25 (e, d) is often useful. 



-JV 



f L- g ^ ^ 

Fig. 25. -Diagrams slightly altered from Lane ('Operative Surges ') to show the modes of 
refreshing and uniting the edges in single hare-lip. In a, p, the angular incision allows two 
flaps to be turned downwards. In c, d, a single flap from the left side is fixed to the opposite 
side, as in Owen's operation. The flap should be much longer than that shown in the figure. 
In e,f, the edges are pared, making the lines of incision strongly concave inwards, g shows 
Golding- Bird's ' rectangular operation ' (vide Brit. Med. Journ. October 1890). 

3. Malgaigne's operation of turning down two opposed flaps may be em- 
ployed ; it is chiefly useful for cases where a notch remains after previous 
operation (a, b). 

4. Perhaps the most generally applicable methods are those shown in 
fig. 25 (e-d, e-f). 

5. The more complicated operations of Giraldes and Collis are seldom 
employed, but it is occasionally very useful to carry the incision round the 
ala of the nose in severe cases ; by this means the depth of the lip can be 
greatly increased ; this plan was, we believe, first employed by Dr. Rawdon, 
of Liverpool. Many other methods are described. Owen's is very good. 

In double hare-lip two special difficulties have to be met, the management 
of the praelabium and of the praemaxilla. The praslabium may be — 

1. Pared at its sides and free extremity so as to make a semicircular or 
tongue-shaped flap which is fitted between the upper parts of the two lateral 
flaps, these having been previously pared. 



Hare-lip — Cleft Palate 171 

2. If long enough, the praelabium may be brought down to make the 
central part of the lip, being pared only at its sides, and the lateral flaps are 
then fitted to it instead of to each other. 

3. The central flap may be removed altogether, and the two sides brought 
together throughout their whole length. 

4. The praelabium, having been dissected away from the praemaxilla, may 
be doubled upon its base and turned up to form a columna for the nose. 
The first and second of these plans are the most generally useful. 

The praemaxilla in some cases may be pushed gradually backwards by 
constant pressure with a pad before the hare-lip is operated on, or it may be 
forcibly pushed back at once ; this is open to the objection pointed out by 
F. Mason, that the wedging back of the praemaxilla may tend to keep open 
the cleft in the palate. Removal of a wedge-shaped piece from the septum 
nasi or of lateral pieces from the praemaxilla is a plan sometimes adopted. 
The method we prefer where the praemaxilla cannot be covered is to shell 
out the bone, leaving the muco-periosteum to preserve the outline of the lip, 
and then bring the lip together ; ' this, we think, is certainly better than entire 
removal of the praemaxilla, which produces flattening of the lip. Where the 
praemaxilla is turned upon a vertical axis so that one edge looks forwards it 
may be forcibly rotated into position, but if the lip can be united over the 
projection the prominence will, as already pointed out, soon diminish. 

Any notch left at the free margin of the lip or at the nostril can usually 
be closed by a subsequent operation. Should primary union fail throughout 
an attempt should be made at once to procure secondary adhesion by either 
putting in fresh sutures, or, if the tissues are too soft and inflamed to hold 
them, by applying strapping to bring the sides together. If the child's 
health is good, this will probably succeed ; failure is, however, often due to 
malnutrition : in such cases union cannot be expected to occur, and a second 
attempt should be put off until the health is improved. It is wiser not to 
operate too soon a second time ; many cases that look unsatisfactory after 
operation improve much in time. Our former house surgeon and old friend 
Mr. Murray of Liverpool, while bringing a flap across very much as in 
Owen's method, uses a button suture to bring up the ala nasi and avoid the 
flattening of the nostril, which is sometimes difficult to obviate. 

The particular mode of operating must be selected for each individual 
case, looking especially to the size of the central portion of the lip in double 
hare-lip and to the inequality of the two sides in the single deformity. 

Cleft Palate. — The varieties of cleft palate have already been mentioned. 
The severer forms are commonly associated with double hare-lip — indeed, it 
is said to be very rare for double hare-lip to occur without cleft palate, and no 
doubt this is true in the complete forms of hare-lip. 

Here a brief account of the modes of treating the deformity can alone be 
given. 

For choice the operation should be performed between the fourth and 
sixth years, but in the less severe cases it may be done as early as the third 
year ; before this it is not wise to attempt it, 2 unless in exceptional circum- 

1 This method was introduced by Sir W. Fergusson. 

- Mr. Clutton has operated successfully in two favourable cases of cleft of the soft 
palate at 12 months old. Lancet, June 6, 1887. 



172 Diseases of tJie Digestive System 

stances, since the risk both of failure of the operation and of the child's 
life is much greater, though some surgeons advocate operation in the second 
or even the first year. Thus Mr. Murray emphasises the opinion that the cleft 
should be closed before the child has learned to talk, so that it may not have 
to overcome the defects of speech which it has acquired if the operation is 
postponed. He therefore closes the lip in complete cases at about the fourth 
week, the soft palate at the end of the first year, and the hard palate later. 
We have operated also earlier than the time we have advocated in slight 
cases, but are not inclined to attempt closure of a severe case of cleft of both 
hard and soft palate earlier than the third year at soonest. As in all plastic 
operations, care must be taken that the child is in good health. The other 
general rules to be observed are : the edges of the cleft must be freely pared, 
all tension must be carefully avoided, the muco-periosteum must be thoroughly 
loosened at the junction of the hard and soft palates in cases of cleft of the 
velum alone, no hard food must be given till union is complete, and if the 
operation is only partially successful or fails altogether, another attempt 
should be made at the end of three months. 

Staphyloraphy, or the operation for closure of a cleft of the soft palate, 
consists in freely paring the edges of the cleft throughout, then a sufficient 
number of sutures are passed, and next the attachment of the soft palate to 
the hard is carefully loosened, and finally, the palate muscles having been 
divided to relieve tension, the sutures are tightened up. The exact mode of 
operating that we prefer is as follows. The child is anaesthetised, a pillow 
is placed beneath the shoulders, and the head allowed to fall right back so 
that the roof of the pharynx is almost horizontal ; in this position light 
enters the mouth well, and the blood and saliva collect in a pool in the 
pharynx instead of irritating the larynx. A gag is then inserted, the whole 
of the cleft carefully pared, and then from four to seven wire sutures are put 
in in the following way : a slightly curved needle in a handle is passed 
through the edge on one side into the cleft, it is then threaded with wire and 
withdrawn, the wire is disengaged, the needle passed similarly through the 
other side and threaded with the end already passed ; this is then drawn 
through the second side by removing the needle, bringing the wire across 
the gap with the two ends projecting on the oral surface. 1 For the uvula we 
often use horsehair sutures. When all the sutures are passed an -incision is 
made through the muco-periosteum of the hard palate down to the bone on 
each side of the front of the cleft and well awayfrom it, the muco-periosteum 
is then carefully detached from the bone all round the anterior extremity of 
the cleft so that the soft parts are quite free and loose. Next, holding all 
the sutures together in the left hand, the palate knife is carried backwards 
and outwards from the incision already made until the levator and tensor 
palati are freely divided and the velum is quite lax. Sometimes it is well 
to divide the palato-glossus and pharyngeus by snipping through the pillars 
of the fauces. If there is no tension it is a good plan to make the relaxation 
incisions after twisting up the wires. A minute or two is then given up to firm 
pressure with a sponge upon the palate, so that all bleeding may be stopped. 
Finally, the wires are twisted up : we usually begin with the middle wires, 

1 For knowledge of this most simple plan we are indebted to our colleague, Mr. 
Hardie. 



Cleft Palate 173 

as they bear tension best. The ends are then cut short, the cleft inspected 
to see that the lips are accurately adjusted, and that there is no tension, and 
the gag is then removed. We usually free the muco-periosteum from the 
bone before passing the sutures. 

Various modifications of the operation are of course well known, and will 
be found described in the general text-books. 

During" the operation it is important to avoid the use of sponges as long 
as possible, since mopping out the pharynx much increases the amount of 
secretion poured out. 

The after treatment. — The hands must be carefully secured to avoid 
injury to the palate, and no solid food should be given for a week. Many 
surgeons give nothing by mouth at all for forty-eight hours, and feed the 
patient by enemata. Others allow milk from the first, and sops after two or 
three days ; others, again, allow soft solids from the first ; probably it is better 
to restrict the diet to milk for two or three days and then allow soup and 
sops till the end of the week ; after this the ordinary diet may be gradually 
resumed, avoiding of course any hard or irritating material. The stitches 
we usually leave to take care of themselves, and nothing more is seen 
of them ; the child probably spits them out. If, however, they are setting up 
irritation, or if after a few weeks they have not come away, they should be 
removed. Any little granulating point or small perforation left at the anterior 
extremity of the cleft will usually heal up of itself ; if it does not do so the 
application of nitrate of silver will sometimes succeed, or in other cases a 
second little operation may be required. 

Only one mode of performing the operation of Ura?ioplasty, or closure 
of a cleft of the hard palate, will be described here ; in our experience it is 
much more successful than the other plans, and if it fails there is less difficulty 
in a second operation than after the so-called osteoplastic method. 

Operation by micco-periosteal flaps consists in paring the edges of the 
cleft throughout, then an incision is made midway between the alveolar margin 
of the palate and the cleft for its whole length down to the bone. The bridge 
of muco-periosteum between the incision and the cleft is then stripped off 
the bone with a blunt raspatory completely into the cleft throughout its 
whole length ; this must be done most thoroughly, so that there is no tension 
upon the flaps, which, however, must not be bruised more than can possibly 
be helped. The sutures are then passed as in the operation upon the soft 
palate and twisted up. 

In case of operation upon the soft palate alone we prefer the plan of 
paring the edges first, then passing the sutures, and then dividing the muscles 
before twisting the sutures ; while in uranoplasty the edges are first pared, 
then the flaps raised, and lastly the sutures are passed and twisted up. 

In quite young children it is an advantage, if there is a complete cleft of 
both hard and soft palates, to close the soft palate alone first and some months 
after to close the hard ; the union of the velum tends to draw together the 
sides of the hard palate during growth and make subsequent closure of the 
cleft more easy. Operation on a complete cleft of both hard and soft palates 
should be reserved for older children, who can better bear the increased 
severity of the more extensive operation. We usually do the whole operation 
at once. 



174 Diseases of the Digestive System 

The shape of the palate are//, already alluded to, is of importance ; the 
higher and narrower the arch the easier in most cases is the closure of the 
cleft, since there is proportionately more tissue to draw across the gap. 

In some children the cleft is so wide, that is, the failure of growth of 
the palate processes is so marked, that it is impossible to close the opening 
by a plastic operation ; in such cases an obticrator should be fitted to the 
gap. Operation is, however, nearly always practicable. 

In some instances the deficiency may be lessened by operation, even 
though complete closure is impossible ; a smaller obturator is then sufficient. 

Obturators are liable to increase the size of the opening by pressure 
unless carefully managed. 1 

The results of the operation are, in successful cases, that the power of 
swallowing is improved, the food no longer tending, to pass into the nasal 
fossse, and the tendency to pharyngeal catarrh is lessened. The voice is not 
improved by the operation itself, but closure of the cleft renders it possible 
by subsequent training to greatly improve speech ; and if sufficient care is 
taken it may be rendered practically perfect ; this no training can do while 
the cleft remains. 

Mr. Mason's plan of completely dividing the soft palate backwards is 
devised to remedy the rigidity of the velum, sometimes resulting after opera- 
tion, which interferes with speech and deglutition. 

A high-pitched roof to the mouth sometimes produces exactly the same 
effect upon speech as a cleft palate ; this has been treated by Mr. Warrington 
Haward by loosening the muco-periosteum and excising a strip : the edges 
of the wound are then brought together so as to lower the pitch of the arch. 
Much improvement followed in his case.- 

Other Malformations. — The rarer forms of congenital malformation 
of the lips require little more than mention here. 

A median fissure of the upper lip is of extreme rarity, but does occur ; 
it results from complete suppression of the lower part of the prefrontal 
process. 3 Mr. Reginald Smith of Warrington informs us that he met with 
such a case in the summer of 1898. 

Cleft of the lower lip has occasionally been met with, as well as a 
peculiar mammillary projection on each side of the middle line. In one 
instance the cleft ran downwards from the angle of the mouth. " Murray is 
quoted by Mason as having seen a case where congenital sacculi existed in 
the lower lip in four members of one family. A similar case is recorded by 
Sympson in the ' Brit. Med. Jour.' December 9, 1882. We have also seen 
more than one of these cases. 

Macrostoma, or congenital enlargement of the mouth, is usually uni- 
lateral, occurs most commonly in females, and is not hereditary ; it may be 
associated with branchial fistulas and supernumerary auricles together with 
hare-lip, as in a case of our own. In Guersant's case, figured by Mason in 
' Surgery of the Face,' the deformity was bilateral and clearly due to failure 
of union of the superior maxillary with the fronto-nasal and external nasal 

1 Coles' modification of Suersen's is probably the best obturator. Vide Brit. Med. 
Jour. November 4, 1882. 2 Lancet, January 15, 1887. 

5 For a discussion on this subject, see Mr. Bland Sutton's admirable lectures, Lancet, 
February 18, 1888, and Tumours, Innocent and Malignant \ 1893. 



Macrostoma — Macrocheilia — Microstoma 



175 




ig. 26. — Macrostoma on the left side, with a faint 
scar-like mark leading up towards a depression at 
the base of a well-marked supernumerary auricle. 
(Mr. Southam's case.) See p. 174. 



processes, i.e. persistence of the lachrymal fissure. 1 In the more usual form 
it is a persistence merely of the great buccal aperture from incomplete fusion 
of the superior and inferior 
maxillary plates, i.e. of the 
maxillary process of the 
pterygo-palatine arch and 
the lower part of the man- 
dibular arch from Avhich 
Meckel's cartilage and the 
lower jaw arise. The con- 
dition is easily remedied by 
paring and uniting the edges 
of the fissure to the required, 
extent. 

IVIacrocheilia, or en- 
largement of the lips, is 
occasionally met with as a 
congenital condition due to 
lymphatic overgrowth or 
enlarged mucous glands 

(cf. also NiEVUS). When the deformity is sufficiently serious to require treat- 
ment, a part of the lip may be removed either by taking out a wedge-shaped 
piece of the whole thickness of the lip or by splitting the lip and removing 
a part of its thickness and afterwards stitching together the edges of the 
mucous membrane. 

The more common acquired macrocheilia or ' thick lip ' is usually due to 
a chronic lymphangitis which is frequently seen in tuberculous children. 
Repeated attacks of acute or subacute inflammation of the lymphatic vessels 
leaves a permanent thickening of the lip behind — a condition analogous 
to elephantiasis. 

Microstoma, or congenitally small mouth, is occasionally seen, and even 
complete closure — atresia. This is treated by enlarging the opening to the 
necessary extent, stitching together the mucous and cutaneous borders, and 
at the corners bringing a flap of mucous membrane across the angle to the skin. 
Similar operations may be performed in cases of cicatricial contraction after 
ulceration, burns, &c. 

In very rare cases the tongue is congenitally absent. 

A common deformity, though not nearly so common as it is popularly 
supposed to be, is tongue-tie or congenital shortness of thefrasnum. Where 
this really exists the tip of the tongue is so tied down to the floor of the 
mouth and inner surface of the jaw that it cannot be protruded, and sucking 
is materially interfered with : slighter degrees of the deformity often exist, 
while in rare cases the tongue is so bound down to the floor of the mouth as 
to be practically immobile (anchyloglossus). Tongue-tie is easily recognised 
by pushing up the tip with the finger in the child's mouth ; its treatment 
consists in snipping through the edge of the fraenum with a pair of blunt- 
pointed scissors and then tearing the rest with the finger nail while the 
tongue is pushed upwards. The division should be made near the jaw, and 
1 Vide also figs, in Forster's Missbildungen des Menschen. 



176 Diseases of the Digestive System 

should not be too free, or possibly the ranine vessels might be injured, or even 
it is said 'tongue-swallowing' occur, from loosening of the tongue muscles 
in the child's subsequent efforts at sucking. A more probable danger is the 
occurrence of cellulitis. 

Sometimes the tongue is malformed, cleft in the middle line, or even 
trilobed, 1 or the muscles of one side may be deficient,'- e.g. as sometimes 
in facial hemiatrophy. 

Sublingual cysts may develop in the median line between the genio- 
hyo-glossi as a result of persistence of the lingual duct which runs from the 
foramen caecum towards the isthmus of the thyroid ; the cavity of these 
cysts is lined with epithelium and contains fatty material 3 {vide p. 179;. 

iviacrogiossia is the term applied to a congenital affection of the tongue 
in which the normal lymph spaces are greatly enlarged and there is also an 
overgrowth of the connective tissue of the part ; there is, in fact, congenital 
lymphangiectasis. The result of this is great enlargement of the tongue, 
which may be kept protruded from the mouth to varying degrees, and by its 
bulk and unwieldiness interferes with sucking and breathing. We have also 
met with slighter degrees of the same condition affecting only the sublingual 
tissue and resembling ranula. Associated commonly with macroglossia is 
hygroma or one form of 'hydrocele of the neck.' This is simply a similar 
condition of the lymphatics of the floor of the mouth and upper part of the 
neck. It appears as a soft, doughy swelling in the submaxillary region, and 
may reach a large size, occupying the greater part of the sides and front of 
the neck {vide chapters on Tumour Growth and on N^vus). 

In severe cases these conditions rarely admit of successful treatment, the 
children are generally marasmic and often otherwise malformed. Removal 
of part of the tongue with the ecraseur or excision of a wedge from it with 
subsequent closure of the gap may be attempted. Galvano-puncture, electro- 
lysis, setons, and injections are all worth thinking of, and pressure and 
astringents are said to have done good in some instances. Our friend Mr. 
Howlett of Hull has recorded a most successful case of the treatment of 
macroglossia by electrolysis. The case was a very severe one, but repeated 
applications, twenty-six in all, completely cured it (vide ' Quarterly Medical 
Journal,' October 1896). It must be remembered that hygroma sometimes 
spontaneously disappears. 

Slighter degrees of the deformity are occasionally met with in older 
patients : in them the condition has a less obvious connection with the 
lymphatics, and appears to be sometimes mere overgrowth of the mucous 
and connective tissues. 

Ranula is the result of occlusion of a mucous duct and the formation 
of a retention cyst, rarely it is due to obstruction of a sublingual salivary duct. 
It appears as a bluish-grey translucent swelling beneath the tongue ; it 
is soft, fluctuant, and painless, but produces deformity from pressure of the 
tongue upwards and the floor of the mouth downwards, and, if large, interferes 
with speech and deglutition. The swelling contains a clear glairy fluid like 
white of egg. Ranula may be treated by excision of a part of the cyst wall 
or by passage of a seton through it ; both methods are frequently successful, 

1 Barling, Brit. Med. Jour. December 5, 1885. 

2 Cholet in Billard's Maladies de V Enfancc. 

3 Bland Sutton, Brit. Med. Jour. February 27, 1886. 



Hypertrophy and Atrophy of the Face 177 

but sometimes fail ; if they do the greater part of the cyst wall should be 
clipped away with scissors and the surface remaining be well scraped or 
rubbed over with solid nitrate of silver. Relapse is believed to be sometimes 
due to the cyst being multilocular. Rarer forms of ranula are said to be due 
to enlargement of a bursa beneath the mucous membrane (bursa of Fleisch- 
mann), or of the one between the genio-hyo-glossi muscles — these may con- 
tain melon-seed bodies. Ranulse connected with the submaxillary duct have 
often been described, but their existence is more than doubtful ; the duct can 
always be made out lying' on the surface of the cyst. Congenital dermoid 
cysts in connection with the branchial clefts are sometimes met with in the 
floor of the mouth : they may attain a large size or remain stationary for 
years ; they contain the usual sebaceous matter, hair, &c. 

A form of cyst arising in connection with the lingual duct which runs 
from the foramen cascum towards the hyoid bone has already been mentioned. 
It is due to persistence of the pharyngeal diverticulum from which the thy- 
roid gland is developed, the thyro-glossal duct. Vide ' Median Fistulas of 
Neck,' p. 179. The dermoid and bursal cysts are to be treated by free 
incision, with scraping and subsequent drainage ; in some cases the cyst 
requires dissecting out through an incision below the jaw. 

We have met with a salivary calculus in a child. 

Other Affections of the tongue. — Papilloma and condyloma of the 
tongue are not rarely seen, as well as naevi and mucous retention cysts. 
Papillomata may be snipped off, condylomata require of course specific 
treatment, mucous cysts should be treated like ranula. 

Nsevus of the tongue is not rare {vide chapter on N.evi) ; puncture with 
the actual cautery is usually the best treatment, but excision of part of the 
tongue may be required. 

Mason has described congenital pendulous fibro-cellular tumours of the 
tongue. 

Hypertrophy and Atrophy of the Face. — In some cases one side of 
the face is congenitally hypertrophied, and continues to grow more rapidly 
than the other side. Nothing can be done for this deformity unless, perhaps, 
ligature of the external carotid were tried. 

Co7tgenital Atrophy, or rather arrest of development of the face, is also 
occasionally seen ; most often it is the result of either some cerebral deficiency 
or of some unilateral lesion, such, for instance, as torticollis ; it may occur as 
an acquired deformity resulting from injury. 

Congenital atresia of the mouth has been already mentioned, but in some 
cases the obstruction is not at the lips, but at the level of the pillars of the 
fauces, and is clearly due to non -absorption of the septum marking off the 
buccal involution from the pharynx. If this rare condition is met with, 
probably free incision and dilatation would relieve the obstruction. 

Actual absence of the mouth with deficient development of the facial 
bones, and instances of apertures below the natural position or on the cheek, 
have been met with. {Vide Billard, op. cit.) 

Ballard has recorded a case of deformity of the jaws produced by thumb- 
sucking, the upper jaw being drawn forwards, and the lower depressed so 
that the face is ' overhung.' L 

1 Path. Soc. Trans, vol. xv. 

N 



i 7 8 



Diseases of the Digestive System 



Branchial Fistulae. — Small orifices large enough to permit the passage 
of a fine probe for distances varying from a quarter of an inch to two or three 
inches are sometimes met with in the neck on one side of the middle line. 
They may occur in the immediate neighbourhood of the external ear or lower 
down in the neck ; the most common position is said to be just above the 
sterno-clavicular joint. The fine channel continuous with these openings 
usually runs upwards and towards the middle line. A little watery mucous 
discharge is often secreted from glands lining the interior of the passage, and 
it is said that occasionally there is a distinct communication with the pharynx. 
These fistula;, which are often hereditary, may be single, or there may be 
two or three of them, and they may be symmetrical. Fragments of cartilage 1 
may be found in their neighbourhood, and it is possible that pharyngeal 
diverticula may result from patency of the internal orifice. 

The presence of these fistulae is due to imperfect obliteration of the 
branchial clefts of embryonic life. 

The most remarkable instance we have seen is that figured. The pinna 
was deficient, and the aperture below allowed ready passage to a finger into 

the pharynx. The aperture 
was closed by a plastic 
operation. 

While the cervical bran- 
chial fistulae are rare, it is 
quite common to see chil- 
dren in whom there is a 
small pendulous body, like 
a molluscous growth, upon 
the cheek just in front of 
the external ear. Some- 
times there is more than 
one of these, and very often 
at the base of the little 
body is a minute orifice 
leading a short distance 
inwards. We have most 
often seen these * super- 
numerary auricles,' as 
they are called, unasso- 
ciated with any other de- 
formity ; but in one instance the child, which had several of these auricles, 
had also macrostoma, double hare-lip, and cleft palate, and a small pendulous 
body exactly like one of the auricles upon the tip of the nose. Our friend 
Mr. Southam has recorded a somewhat similar case (fig. 26), and Mr. J. H. 
Morgan another. Cervical 'auricles' are also met with (vide fig. 28). 

The cervical branchial fistulas represent the clefts between the hyoid and 
thyrohyoid arches, or between the thyrohyoid and subhyoid, or again between 
the subhyoid arch and the upper boundary of the chest, while the presence of 
aural fistula occurring, as it sometimes does, in the helix or elsewhere, is due 

1 Treves records a case in which a rod of cartilage existed, but no fistula {Path. Soc. 
November 1, 1887). We have seen a similar case. 




Fig. 27. — Branchial fistula in a girl. Traces of the 
pinna are seen above the fistula. 



Branchial Fistulce, &c. 



179 



to persistence of one or more of the fissures between the 'tubercles ' of which 
the pinna is built up, 1 the supernumerary auricles themselves representing 
displaced or ununited ' tubercles.' 

The common ' supernumerary auricles, which may or may not have a little 
pit at their base,' are thought by Sir J. Paget to be probably 'growths of the 
same opercular skin fold as the auricle, from which they look like bits de- 
tached, or they are auricles displaced, but still in the line or region of the 
mandibular arch.' - 

The auricles, sometimes at least, contain cartilage, and the association of 
enchondroma of the parotid occurring in later life with disturbance of the 
development of these parts has been pointed out by Mr. Jacobson. 3 

In very rare instances an orifice is met with in the median line of the 
neck. Of this we have seen four cases, two of our own and two in the 
practice of our colleagues ; in one there 
was a seam in the skin closely resembling 
the scar of a tracheotomy wound, and in 
the centre of this, just above the sternum, 
was a small opening ; in the second case 
there was a discharging fistula over the 
lower part of the thyroid cartilage. These 
median apertures may be explained by 
failure of the branchial arches to close 
in the middle line, or possibly by a 
deficient closure of the ' sinus cervicalis.' 
It is, however, most probable that such a 
fistula, the ' thyro-glossal duct ' or ' canal 
of His,' is, in the words of Dr. C. F. 
Marshall, who has kindly sent us his 
paper on the subject, ' a remnant of the 
middle thyroid rudiment of His. It is 
not difficult to imagine,' he says, 'that 
this may gradually become dilated at its 
lower end into a sac by the secretion of mucus from the wall of the canal, 
and that this sac ultimately causes the skin to give way by its pressure 
till a sinus is formed.' Dr. Marshall, in his interesting 'paper, points out 
that these fistulas are not present at birth, but appear later, a strong point 
m support of his view, which is now generally accepted. 4 

H. E. Durham in the ' Med.-Chir. Trans. ' 1894, points out that the proof 
of a fistula being derived from the thyro-glossal duct depends upon— 

1. A median position. 

2. A ciliated epithelial lining. 




Fig. 28. — Supernumerary auricle in the neck. 



1 Vide Mr. Bland Sutton's Lectures, Brit. Med. Jour. February 19, 1887, and Lancet, 
February 1888, and his book on Tumours, 1893. 

- Sir J. Paget (Med.-Chir. Trans. 1878), from whose writings much of our information 
on the subject is taken. 

3 Vide Guys Reports. 

4 Vide Sir J. Paget, op. cit. ; also Tillaux and others, Le Proves Medic. February 21, 
1885 ; Dr. C. F. Marshall, Jour, of Anat. and Phys. vol. xxvi. ; also St. Thomas's Hospital 
Reports, 1890, and Brit. Med. Jour. May 1890. 



180 Diseases of the Digestive System 

3. Permeability through the foramen caecum. 

4. Paired lumina resulting from the original bifurcation. 

5. The presence of thyroid gland follicles. 

6. A connection with the thyroid gland below. 
The first two points are the most important. 

As these branchial fistulas give rise to very little inconvenience, it is usually 
best to leave them alone, especially as they are intractable to treatment from 
the difficulty of thoroughly destroying their secreting surface. The passage 
of a hot wire down them, or passing a probe in and then dissecting round it, 
or the use of the galvanic cautery, is the plan usually advised. In the second 
of our median fistulas, in which there was a 'pinching' pain in the part, we 
with some trouble succeeded in obliterating it for a time by several applica- 
tions of nitrate of silver fused upon a wire and passed well up the track ; 
subsequently, however, fresh secretion occurred, and even excision failed to 
entirely cure the condition ; however, complete excision of the whole fistulas 
is the only at all certain method of cure, and this may involve a somewhat 
troublesome dissection. 

Supernumerary auricles should be simply snipped off. They consist of 
a small rod of yellow elastic cartilage covered with integument, and are 
supplied with a small artery. 

Instead of fistulas, congenital dermoid cysts may be found marking the 
sites of the various fissures &c. of the embryo {vide chapter on Tumour 
Growth). Clutton has described a case of congenital papilloma in the line 
of the branchial fissures ; and cases of primary carcinoma in the neck, pro- 
bably taking origin in relics of the branchial clefts, have been recorded. 

In some of these patients the lower jaw is imperfectly developed. 

By far the best account of the various developmental abnormalities will 
be found in Bland Sutton's interesting ' Tumours, Innocent and Malignant ; ; 
Cassell & Co. 1893. 

Any part of the digestive tract may be the seat of congenital malforma- 
tion in addition to those already described. Congenital strictures l and 
pouchings' 2 of the oesophagus, tracheal fistula, 3 displacements of the stomach, 
obliteration of the pylorus, absence of portions of the intestinal canal, and 
displacement of its various segments, are all met with, and in certain cases 
may have some surgical importance; they cannot, however, be -discussed 
here. We have recorded a case of pouching of the oesophagus which was 
probably congenital and inherited, inasmuch as mother and son both appa- 
rently had it. Mr. Butlin has also recently recorded cases. Enterotomy 
might possibly be of service in some cases of congenital intestinal deformity 
where the obstruction was low down (vide -p. 148). 

1 Charlewood Turner mentions seven cases in Ziemssen. Vide Path. Soc. Trans. 
1885. 

2 Sir Morell Mackenzie states that congenital pouching is extremely rare. 

5 May be combined with oesophageal deficiency usually at the middle third of the 
gullet. The fistula is a persistence of the embryonic condition (Sir M. Mackenzie). 



I8l 



CHAPTER X 

DISEASES OF THE LIVER 

In examining the liver of an infant or young child, it must be borne in mind 
that this organ is proportionately larger in the child than in the adult ; it 
consequently occupies a greater space in the abdominal cavity, and thus to 
the inexperienced it may appear to be enlarged, when in reality it is only of 
normal size. The fact pointed out by Sahli must not be forgotten, namely, 
that the angle made by the lower ribs with the tip of the sternum is wider in 
children than adults, so that more of the liver is left uncovered in the former 
than in the latter. 

The upper limit, as determined by percussion, reaches to the fifth space 
at the right edge of the sternum, to the upper border of the sixth rib in the 
nipple line, the seventh in the axillary, and the ninth posteriorly, though the 
deep dulness reaches somewhat higher. While the edge of the right lobe 
does not in an adult extend below the costal arch in the recumbent position, 
in a child it always does. The size of the liver can be as readily estimated 
in a child as in an adult by percussion if the stomach is not over-distended ; 
the lower edge can, however, be much more readily felt in a child than in an 
adult by placing the warm hand on the abdomen and gently pressing back- 
wards and upwards. In most cases it can be easily determined if the edge 
is round, sharp, irregular, or flabby as in acute yellow atrophy. 

The liver is not often smaller than natural during childhood ; it is so only 
in the rare instances of the occurrence of acute yellow atrophy or cirrhosis, 
and even in these cases it is frequently enlarged, a result which is due partly 
to its vascular nature, its veins being very readily distended, and partly also 
to the ready way in which it appears to store away fat. 

The best instance of its enlargement from mechanical causes is afforded 
by the congestion which so frequently attends heart disease, where, in conse- 
quence of regurgitation through the mitral valves, there is an obstruction to the 
onward flow of the blood. It is enlarged also in mediastino-pericarditis for 
a similar reason. There appears also often to be a temporary enlargement 
and a sluggish circulation in many cases of chronic intestinal catarrh, where 
there is said to be a functional derangement of the liver, accompanied by loss 
of appetite and pasty constipated stools deficient in bile and an excess of 
pigment and perhaps uric acid in the urine. The liver is frequently enlarged 
from the presence of excess of fat ; more rarely it is amyloid, or the seat of 
new growths or of abscess. 

The weight of the liver at birth is about 4^ oz. or 4-2 per cent, of the body 



1 82 Diseases of the Liver 

weight (Birch-Hirschfeld). At a year old 1 1 oz. or 3-4 per cent, of the body 
weight (Holt). In the adult the weight of the liver is 2*5 per cent, of the body 
weight (Frerichs). 

Jaundice 

The common form of jaundice occurring in newly born infants has already 
been discussed ; the rarer form in which jaundice is due to lesion of the bile 
ducts may be here referred to. 

Congenital Stricture or Obliteration of the Bile Ducts. — In these 
curious cases an obliteration of the common hepatic ducts appears to take 
place, which leads to a secondary or biliary cirrhosis of the liver if the infant 
survive for a few months. The child may die from haemorrhage from the navel 
or gastro-intestinal canal during the first few days of life. Such cases, though 
not common, are by no means rare. Among the more recently recorded cases 
are those of Wickham Legg, Glaister and John Thomson ; we have seen 
several cases in which autopsies were made. 

Symptoms. — The infant is jaundiced from birth, the yellow colour being 
intense, affecting the skin, conjunctivae, mucous membrane, and urine ; the 
stools are pale and completely devoid of bile. The infant frequently suffers 
from haemorrhages, the stools then being black and the skin covered with 
ecchymoses. In one of our cases the motions were stated by the mother to 
be black immediately after birth. The liver may be enlarged. Such children 
may live for a few months ; two of our cases lived to be 4^ months old. The 
following case illustrates some of these points. 

Congenital Absence of Hepatic Ducts. Biliary Cirrhosis. -—John H., aged 6 weeks, was 
brought to the out-patient department on October 4, 1883, with the following history : 
Mother states he was an eight-months child, born after a tedious labour. About a week 
after birth it was noticed he was jaundiced (midwife states he was yellow when born) ; his 
urine was dark and stained the linen ; the stools were loose and pale grey in colour ; he 
did not ' snuffle,' and there never was any rash. On examination, when 6 weeks old, he 
was deeply jaundiced ; fairly well nourished ; the edge of the liver was felt immediately 
below the ribs. October 8. — Much the same ; diarrhoea troublesome, pale white milky 
stools. October 25. — The liver is enlarged, the edge being felt nearly on a level with the 
umbilicus ; it has been increasing in size the past week or two. November 1. — Liver still 
enlarged ; stools loose, resembling milk ; still intensely jaundiced ; is becoming very thin. 
December 6. — Liver decidedly less; diarrhoea not so troublesome; continues to waste. 
December 30. — Diarrhoea has been very troublesome ; convulsions. Death when" 4 months 
old. LL had not at any time suffered from purpura or haemorrhages. 

Post-mortem. — Body extremely emaciated and deeply jaundiced; all internal tissues 
bile-stained. Heart, muscular walls pale yellow ; kidneys ditto. Liver, 7 oz. ; does not 
appear enlarged ; is of a dirty dark green colour, surface finely granular ; no adhesions or 
peri-hepatitis or matting of parts in the fissure ; it has a tough feel, and creaks under the 
knife as it is cut ; the section shows a dark green colour with strands of fibrous tissue, much 
in excess of the normal state, accompanying the portal vessels ; the strands are best marked 
near the entrance of the vessels at the fissure, and the larger bile channels are more or 
less dilated and contain thick green bile. On examining the inferior surface of the liver, 
the gall bladder is seen distended with a non-biliary mucoid fluid ; its duct can be traced 
downwards, though smaller than normal, to the ductus choledochus ; the latter joining the 
duodenum in the normal position is pervious and contains mucus only. No trace of a 
right or left hepatic duct-can be found. The portal vein and hepatic artery are apparently 
quite, normal. Microscopical examination of liver shows excess of fibrous tissue sur- 
rounding portal vessels and lobules ; many small biliary ducts are seen choked with 
inspissated bile. 



Congenital and Catarrhal Jaundice 183 

Diagnosis. — The obstructive jaundice of the newly born can be readily 
distinguished from functional jaundice, the only form likely to be confounded 
with it, by the stools in the former being colourless while the latter contain 
bile. 

Morbid Anatomy. — There is much emaciation, the internal organs are 
intensely bile-stained, with minute haemorrhages on their surfaces. The 
liver is mostly enlarged and of a dirty green colour ; the surface is granular, 
the granulations varying in size from a millet seed to a hemp seed : it has a 
tough feel, and on section an excess of fibrous strands is seen accompanying 
the portal vessels — this is most marked at the great fissure ; the larger 
biliary channels contain green inspissated bile. On examining the vessels 
in the transverse fissure, the vein and artery are intact, but the gall bladder 
is usually small and contains no bile, and the common and hepatic ducts are 
either shrivelled up and nearly obliterated or greatly diminished in size. 
Microscopical examination of such livers shows biliary cirrhosis. The 
etiology of these cases is obscure ; in some cases apparently the ducts are 
never formed. In one of our cases the mother had suffered from syphilis, 
but neither of the infants showed any symptoms. It is possible that a 
catarrh of the bile ducts occurring during fcetal life or a blockage from 
inspissated bile might lead to a permanent obstruction and obliteration. 
The cirrhosis follows as a result. 

Prognosis. — Such cases are necessarily fatal in a few months, and hardly 
admit of any treatment. 

Obliteration or Stenosis of the Common Bile-duct occurs during 
childhood apparently as the result of an inflammatory lesion in the lower 
part of its course ; the head of the pancreas may also be involved. In one of 
our cases a girl of 5 years became jaundiced for the first time when recover- 
ing from whooping cough ; she remained jaundiced till her death seven 
months after ; death took place from haemorrhage into the bowels. At the 
post-mortem the lower portion of the common duct was found surrounded 
by fibrous tissue, and would only admit a probe of one millimetre in diameter. 
The head of the pancreas was indurated ; the gall bladder was very small 
and contained mucus only. In a second case, that of a girl seven years 
of age, there was jaundice for three years before death. In this case oblitera- 
tion of the lower portion of the common duct had taken place and a gradual 
dilatation of the biliary tract above, which formed into an enormous bile 
containing cyst. This was tapped and drained during life ; death was the 
result of an attempted operation to connect the cyst with the duodenum. 1 

Catarrbal Jaundice. — Children of all ages are apt to suffer from a 
temporary jaundice, associated with gastro-intestinal catarrh, attributable to 
a swollen condition of the mucous membrane of the duodenum and common 
bile duct. 

Symptoms. — After a few days, in which there are symptoms of dyspepsia, 
the conjunctivae and skin become yellow, the urine contains much pigment 
and the stools are pale. A few days later the liver may be felt to be en- 
larged. There are rarely the nausea, low temperature, and slow pulse so 
often seen in the catarrhal jaundice of adults. We have, however, seen one 

1 See Medical Chronicle, Oct. 1898, and also case of Treves, Practitioner, Jan. 
1899. 



184 Diseases of the Liver 

or two cases in which there were jaundice, delirium, drowsiness, and slight 
fever, in which we suspected acute yellow atrophy, yet they finally recovered 
and we were left in doubt as to their nature. As a rule, in the course of a 
few days or a week all the symptoms disappear. 

The diagnosis of catarrhal jaundice does not usually give rise to 
difficulty when it occurs in children. The possibility of the jaundice being 
due to acute yellow atrophy must be borne in mind, and any ecchymoses 
or brain symptoms would be very suggestive of the latter. Jaundice 
due to cirrhosis, or new growth, or syphilitic disease, could hardly be 
mistaken, as jaundice under these circumstances would not be an early 
symptom. It is possible that jaundice may be due to round worms finding 
their way into the duodenum, and entering the common duct. 

Treatment. — The treatment of catarrh of the bile ducts should be similar 
to that of gastric catarrh : the diet consisting of beef tea, bread sops, light 
puddings, and milk. Sulphate or phosphate of soda may be given with 
infusion of rhubarb two or three times a day, Carlsbad salts or Friedrichs- 
hall water are useful in keeping the bowels open. 

Epidemic or Infectious Jaundice. — On one or two occasions we have 
observed limited outbreaks of jaundice in children, accompanied with vo- 
miting and fever. On one occasion this occurred among visitors, chiefly 
children, at a seaside resort in August. In some instances jaundice appears 
to have been a symptom in some influenza epidemics. Kissel and some 
other authors have described attacks beginning w T ith fever, headache, 
shivering, vomiting, then jaundice supervening in a few days. The liver is 
enlarged ; the stools in some cases retained their normal colour. In some 
cases there appears to be albuminuria. But little is known about these 
attacks. 

Acute Yellow Atrophy of the Liver 

This curious and interesting disease appears to occur at all periods of 
life, infancy and childhood not excepted. Several Continental writers have 
described cases occurring in infants a few days old, but whether these were 
in reality true cases of yellow atrophy may be open to doubt. Undoubtedly 
infants who are jaundiced shortly after birth die in the course of a few days 
or weeks with symptoms of acute disease, but, as far as can be judged from 
the reports, the naked-eye appearances of the liver after death were not 
those usually found in acute yellow atrophy. In such obscure diseases as 
those named after Buhl and Winckel, jaundice occurs. While this disease 
cannot be said to be common at any time of life, it is perhaps rarer in 
childhood than in early adult or middle life, though it is very probable that 
cases are not infrequently overlooked, inasmuch as some of the recorded 
cases were not diagnosed during life. That they are not rare is certain, as 
Dr. Hyla Greves has collected seventeen cases beside one observed by 
himself. We have seen several cases, one of which occurred in a boy of four 
years, another in a girl 3^ years, and we have had the opportunity of examin- 
ing the liver in a case of Dr. Railton's. 

Symptoms. — The disease begins insidiously ; the first symptoms are 
chiefly those of catarrhal jaundice, loss of appetite, constipation, and jaundice, 
the stools are mostly pale but sometimes quite normal, and the urine is bile- 



Acute Yellow Atrophy of the Liver 185 

stained. The patient usually remains in this condition for a week or two, 
during which time neither his friends nor medical attendant suspect the 
serious nature of the disease. The liver at this period is enlarged and in some 
cases distinctly tender, the edge may have a flabby feel. Then come distinct 
cerebral symptoms which may not improbably be mistaken for the onset of 
tubercular meningitis. The child is irritable, vomits repeatedly, rambles at 
night, is perhaps very delirious or convulsed ; the pupils are generally dilated. 
There are often ecchymoses about the body at the seat of slight injuries, and 
oozing of blood from the gums and oedema of the feet and face. After a 
few days the child passes into a condition of coma ; there are also 
probably muscular twitchings, spasms of several groups of muscles as the 
masseters, and perhaps local paralyses. The urine may contain leucin and 
tyrosin. In the latter stages the liver diminishes in size, but this is 
not invariably the case. The following case illustrates some of these 
points : 

Acute Yellow Atrophy of Liver. — Stephen T. , aged 4 years. Admitted September 27, 
1882. Mother dead. Xo history of congenital syphilis could be obtained. Father is a 
labourer in poor circumstances. Child has been much neglected, and often had insufficient 
food. Four weeks before admission child took very little nourishment ; became yellow 
and was constipated. Fourteen days ago vomiting began, and lately he had been delirious 
at night and queer in his ways. Present state. — Patient is a well-developed boy ; moderate 
jaundice ; there is oedema of both eyelids, back of hands, and dorsum of both feet. He 
is frequently mumbling to himself, and does not readily understand what is said to him. 
His tongue is red at the tip and edges and coated on dorsum ; he is very thirsty, but 
almost constantly vomits his milk immediately after it is taken. Abdomen somewhat dis- 
tended ; edge of liver distinctly felt below costal arch and in epigastrium, and on per- 
cussion dulness extends upwards to the fourth space. The tip of the spleen is felt below 
the tenth rib. Heart's sound normal ; no marked physical sign in chest. Urine passed 
with faeces or in bed ; some separated from faeces contained bile pigment ; no albumen ; 
no leucin or tyrosin under microscope. Faeces, passed a few hours after admission, were 
solid and of a dark brown colour. Pupils dilated, but act to light. Pulse, 100, weak ; 
temperature, 99 F. Second day (of admission). — Vomiting continued most of day, but 
less after peptonised milk was given. Temperature, 96'4 c -ioo'2°. Third day. — Less 
vomiting; haemorrhage from mouth, apparently from gums; bowels acted once after 
calomel, solid brown motion ; no urine passed for twenty-four hours. Temperature, 
96°-ioi - 2 c , 97-8°-io2-8°. Fourth day. — Child has been delirious, with some muscular 
twitchings of face and neck. This morning, left facial paralysis noticed not affecting the 
eye ; it is well marked when child cries, but not complete ; no paralysis elsewhere ; pupils 
dilated and sluggish ; child only semi-conscious ; several loose stools passed after calomel, 
the first light yellow, later pale grey colour ; no urine obtained ; edge of liver very dis- 
tinctly felt below costal arch. Pulse, 100, weak; temperature, 102-8°, 104=, 102 "6°, 101 . 
Fifth day. — Much worse ; is quite unconscious ; head and eyes turned to right ; all limbs 
extended and rigid ; spasms of jaws causing constant grinding of teeth ; breathing 
stertorous ; no optic neuritis, but veins are full and somewhat tortuous. Pulse, 130, weak ; 
temperature, ioi'2°-ioo c . Died in afternoon. 

Post-mortem (twenty-two hours after death). — Body well nourished ; skin very yellow ; 
much hypostatic congestion of dependent parts of the back and arms and legs ; ' coffee- 
ground ' material oozing from mouth ; no rigor mortis ; slight oedema ; a bruise about 
size of a penny is visible on the sub-clavicular region, left side. Chest : no fluid, old 
adhesions left side ; right lung on section showing numerous small haemorrhages into sub- 
stance of lung ; both lobes are gorged. Left lung : there is a solid portion in upper 
lobe, reaching anterior surface and corresponding in a position with above-mentioned 
bruise, involving the whole thickness of the lobe, but not the inner or outer edges. On 
section this solid portion consists of red hepatisation with a blood clot in centre and at 



1 86 Diseases of the Liver 

circumference; lower lobe gorged and containing small haemorrhages. Bronchi contain 

blood and mucus. Heart, 2^ oz. : left side contracted, containing a few strings of yellow 
fibrin ; walls of heart pale yellow and fatty ; no endocarditis ; haemorrhages into sheath of 
aorta. Abdomen : on opening, a few ounces of bile-stained fluid escaped. Much injection 
of small vessels of mesentery in the neighbourhood of the liver ; one haemorrhage, size 
of walnut, in mesentery of descending colon. Stomach contained coffee grounds; 
duodenum also darkish contents ; rest of small and large intestines contained pale yellow- 
semi-fluid contents. Spleen, 3 oz., firm : somewhat enlarged but normal. Kidneys, 
4.5 oz. : cortex pale yellow, and has a glistening appearance from presence of fat ; pyramids 
congested. Brain \ nothing abnormal at base, but convolutions on upper surface are 
decidedly flattened ; the ventricles are distended with turbid fluid, and the parts around, 
especially the white portions, are softened and easily wash away under a stream of water ; 
no lesion of pons or softening noted elsewhere ; no haemorrhage. Liver, 12^ oz. : it is 
very limp, and capsule wrinkles on doubling up. Right lobe : upper and lower surfaces 
are irregular from presence of some portions which are more elevated than others ; the 
more elevated portions are greenish yellow, and the others red. On section, bright 
orange-yellow and red portions are seen ; the lobules are not readily seen in the yellow- 
parts, which are soft. In the red, which are firmer, the lobes can be distinguished, the 
centres being bright red and the circumference pale. The left lobe contains more of the 
red parts and the right more yellow. Microscopical examination. — Red portions, the 
intralobular veins are normal, the walls of the interlobular veins contain numerous 
leucocytes, and the surrounding connective tissue is also infiltrated ; the lobules contain 
no hepatic cells, but hyperplastic stroma, leucocytes, many red corpuscles. The biliary 
capillaries are very prominent objects, and seem to contain epithelium with nuclei under- 
going subdivision. Yellow portion — The lobules are large ; central vein normal ; hepatic 
cells swollen ; nuclei obscured ; fine granular contents and bile pigment. The walls of 
interlobular veins infiltrated with leucocytes. Biliary capillaries stuffed with epithelium. 

Diagnosis. — Malignant jaundice in an early stage cannot be distinguished 
from catarrhal jaundice ; it is only when cerebral symptoms appear, and 
there are dilated pupils, ecchymoses, or constant vomiting, that the suspicion 
is raised that there is something more than simple jaundice. At this time 
the case is liable to be mistaken for meningitis, though the presence of 
jaundice and cerebral symptoms should indicate the true nature of the dis- 
ease. It may possibly be confounded with pyaemia, phosphorus poisoning, 
or pneumonia with jaundice, but in all these the jaundice would as a rule 
follow and not precede the other symptoms. 

Morbid A natomy.— Organs bile-stained ; haemorrhages in various organs. 
Liver small, limp in texture, mostly bile-stained, some portions being greenish 
yellow, others orange-red, often bulging in some parts from shrinking in 
others. On section, there are usually areas of red or yellow colour in which 
the lobules are indistinct or entirely indistinguishable. 

Treatment. — Unfortunately but little can be said under this head, as 
such cases have been invariably fatal. 

Cirrhosis of the Liver 

Cirrhosis of the liver is not a common disease during early life, being 
much rarer than among adults. Toedten met with it thirteen times out of 
880 post-mortems made during seven years at the Children's Hospital at 
Munich. Of the various causes of cirrhosis alcoholism necessarily takes the 
first place. Cases of alcoholic cirrhosis have been reported by various 
authors, Frerichs, Bamberger, Toedten, Howard, and others. Sir S. Wilks 



CirrJiosis of the Liver 187 

has recorded the case of a girl, aged 8 years, who had taken daily for some 
time half a pint of gin. Syphilis is by far the commonest cause of an 
interstitial hepatitis occurring in early life, more especially during infancy, the 
liver being enlarged and the infant jaundiced, but it is doubtful if syphilis 
gives rise to the typical hobnail, cirrhotic liver. Gumma of the liver 
may make their appearance about puberty, and cicatrisations are formed 
which may involve the portal vein and give rise to ascites. There is little 
evidence to point to the interstitial hepatitis of infancy passing on into the 
typical hobnail liver seen occasionally in older children. Possibly the 
slighter forms of it which are not fatal do so. Tuberculosis, especially of 
the peritoneum and abdominal organs, occasionally gives rise to a peri- 
hepatitis and also cirrhosis of the liver. It must be said, however, in a 
goodly number of cases of cirrhosis of the liver during childhood, there is 
no history of alcoholism or syphilis, nor any evidence of tuberculosis. Such 
cases have been reported by Mitchell Clarke, W. Edwards, and others. 
In some of these cases the symptoms of cirrhosis have been preceded by 
attacks of one of the fevers, as enteric, scarlet fever, whooping cough, and 
it has been suggested that there is more than a casual connection between 
the two. However, considering the great frequency of these fevers and the 
rarity of cirrhosis, great caution is required in drawing any conclusions. In 
a certain number of cases perihepatitis is found without marked cirrhosis, as 
in chronic peritonitis, pleurisy, pericarditis and mediastinitis. Symptoms 
and course. — The symptoms are mostly those found in the adult. Dyspepsia, 
slight jaundice, epistaxis, anaemia and marked enlargement of the spleen, and 
later ascites. Often the evening temperature is raised a degree or two. 
The course is usually chronic ; the ascitic fluid forming again and again 
after being tapped ; death being preceded by coma. The commonest cause 
of ascites during early life is tubercular peritonitis ; the next commonest 
cause, apart from cardiac and renal disease, is mediastinitis. Ascites with 
enlarged spleen is usually due to cirrhosis, and would mostly distinguish an 
ascites due to cirrhosis from chronic tubercular peritonitis or mediastinitis. 
We have seen several cases in which the diagnosis of ' enlarged spleen : 
was made and which eventually turned out to be cirrhosis of the liver. 

Morbid A?iatomy. — The liver may be found either enlarged or atrophied, 
but usually the former. The surface is hobnailed, and the liver creaks on 
section. In syphilitic livers there may be gummata, cicatricial depressions 
and bands of fibrous tissue running irregularly through the liver substance. 

Treatment. — The treatment of portal obstruction, the result of a cirrhotic 
liver, is only palliative, for there is but little reason to hope that even in syphi- 
litic disease there is much chance of modifying in any way the fibrous tissue 
which is strangulating the portal channels in the liver. Relief must be sought 
by unloading the portal system by purgatives and diuretics and by removing 
the ascitic fluid by tapping ; the latter is best performed by means of Southey's 
trochars. In syphilitic cases the local inunction of mercurial ointment and 
other specific treatment should be tried. 

The following case of cirrhosis of the liver illustrates the above remarks : 

Cirrhosis of Liver. — Bertha S. , aged 10 years, was admitted to the Children's Hospital, 
Manchester, November 5, 1894. It was stated that the patient had had measles, whoop- 
ing cough, enteric and scarlet fever ; the latter when eight years of age, followed by 



1 88 Discuses of the Liver 

nephritis and dropsy. Thechild's mother is addicted to alcohol, and has been in :i ' Retreat ; ' 
the child herself has never had alcohol given her. Her present illness began with jaundice 
about fourteen months ago, then the abdomen began to swell. Present state. She is a 
f.niU nourished girl, with slight jaundice, no ascites or anasarca. Gums swollen and spongy, 
and bleed easily. The edge of the liver cannot be felt, the spleen is much enlarged, the 
inner border can be felt reaching forward nearly to the umbilicus and down to the iliac 
crest. No abdominal tenderness. Examination of the blood shows 4,230,000 red cor- 
puscles per cub. cent., normal in size and shape. No excess of leucocytes. Haemo- 
globin, 49 per cent. No albumen in the urine. Other organs healthy. Later in the 
month it became evident there was ascites. There was also some smart epistaxis on one 
occasion. The ascites became more marked, and on December 4 she was tapped with a 
Southey's cannula and some nine pints withdrawn. After the tapping the spleen was felt 
as before, but the edge of the liver was not felt. She was tapped three times in December, 
thirty pints being withdrawn in all. In January, thirty-six pints were withdrawn. In 
February, twenty-eight pints. She died on March 23, having been comatose for several 
days. Throughout her illness, the evening temperature rose to 100F., but was normal 
in the morning. No albumen was ever found, nor was there any general oedema. At the 
post-mortem there was no perihepatitis ; the liver was small, weighing 15^ oz. Both 
surfaces were irregular, showing small hobnail projections. On section the substance 
was tough, and bands of fibrous tissue were seen running through the section. The spleen 
was enormously enlarged and solid. Weight 135 oz. There were one or two small granu- 
lations on the mitral valve. 

Syphilitic Interstitial Hepatitis.' — The liver is frequently found en- 
larged in infants suffering from hereditary syphilis, more especially during the 
exanthematous stage, or it may be enlarged in newly born syphilitic infants. 
Hochsinger noted enlargement of the liver in 46 out of 148 cases, of which 
30 got well and 16 died. In the most marked cases, especially if the infant 
is poorly nourished, the outline of the enlarged liver may be seen, as well as 
the edge distinctly felt. The edge is smooth and the liver feels hard. 
The spleen is also enlarged. Ascites hardly ever occurs and jaundice is 
rare, though a slight yellowish tint of the conjunctiva is sometimes present. 
The liver at the ftost-mo7'tem in typical instances is found enlarged, of a 
tawny or yellowish colour, with smooth surface and a tough and elastic feel. 
On section the same tawny colour is seen, the acini are indistinct or 
cannot be distinguished ; there may be numerous whitish points seen, the 
so-called miliary gummata. Microscopically there is a diffuse infiltration 
of small cells in the connective tissue between the lobules and surrounding 
the portal system, and also thickening of the arteries. The small gummata 
consist of small round cells, connected with the smaller branches of the 
portal vein or biliary capillaries (Birch-Hirschfeld). Embryonic tissue and 
excessive amount of connective tissue are usually seen in a later stage. 

In less advanced cases there may be no marked enlargement of the 
liver, or no very characteristic appearances to the naked eye, but micro- 
scopically commencing interstitial hepatitis may be found. 

The following case may be taken as a typical illustration : 

E. B., ten weeks old, was admitted to hospital January 1899. An older brother 
suffers from syphilitic brain diseases (general paralysis and dementia). The infant was 
born health}-, but recently it had suffered from coryza, rash, and enlarged abdomen. On 
admission he was well nourished, there was marked coryza, somewhat hoarse cry, coppery 
scaly rash round mouth, remains of an erythema about buttocks, abdomen distended and 
tympanitic, the veins on surface enlarged, edge of liver felt reaching nearly to umbilicus, 



Tuberculosis of the Liver 1 89 

spleen much enlarged. The infant died shortly after admission, being slightly jaundiced 
before death. Post-mortem. — Brain healthy, lungs slight hypostatic pneumonia with some 
minute haemorrhages, heart normal, abdomen contains about an ounce of yellow cloudy 
fluid, a few flakes of lymph in fissure of liver and on intestines. Liver enlarged i2§ oz., 
yellow tawny colour, surface smooth, firm, tough, and elastic in consistence. Cuts with a 
creaking noise ; on the cut surface, which is of a dirty yellow colour, in places the lobules 
are indistinguishable ; in other places, where the colour is more reddish, their outline is 
faintly visible. A few whitish pin-head points seen in parts. No strands of connective 
tissue visible, no large gummata. Spleen, o.\ oz. , enlarged, firm, purple-red, flakes of 
lymph on surface. Microscopically there was infiltration of small cells surrounding the 
portal capillaries and between the acini of the liver. 

In older children gummata and cicatrices are found at times on the 
surface of the liver ; with this there may be more or less cirrhosis, giving rise 
to portal obstruction and ascites. See p. 187. 

Patty Iiiver 

The liver becomes! enlarged from being infiltrated with fat in several 
different diseases during infancy and early childhood. It is common to find 
children who are fat, pale, and rickety, with large livers, the edge of the 
right lobe reaching nearly into the iliac fossa and the left to the umbilicus. 
If an opportunity occurs for a ftost-mortein examination, such livers are found 
to be pale and greasy, the lobules being indistinct, and the cells are seen 
microscopically to be loaded with fat. Such children are usually anaemic, 
have large distended abdomens, coated tongues, pasty stools, and surfer from 
chronic indigestion. Under a careful dietary, small doses of mercurials and 
salines, such as Carlsbad or Rubinat water, improvement gradually takes 
place and the liver diminishes in size. 

Tuberculosis of the liver 

Although it is exceedingly common to find tubercles in the liver in children 
dying of general tuberculosis, it is exceedingly rare for these tubercles to have 
given any indication of their presence during life. Tubercular disease of the 
liver generally takes the form either of grey miliary tubercles scattered through 
the organ and on the surface, or of cheesy nodules, rarely larger than peas or 
at the most small marbles, which appear to have a special preference for the 
neighbourhood of the bile ducts. These caseous masses may be found bile- 
stained on section, and small cysts formed of dilated bile ducts filled with 
inspissated bile may be found which have been caused by compression of the 
ducts. Jaundice is rarely produced unless there are enlarged caseous glands 
in the transverse fissure compressing the common duct. In very rare instances 
caseous masses appear to form in the liver, resembling the caseous masses 
seen in the brain : these may cause enlargement of the liver and gradually 
soften down into a chronic abscess. We have seen only one case of this 
kind. The history was as follows : 

Chronic Tuberculosis. Hepatic Abscess. — Boy, aged 14 years, father and mother 
dead; never been out of England; admitted December 21, 1880; recently had pain 
in right side and cough ; an anaemic boy ; yellowish conjunctiva ; pain and tenderness 
about hepatic region ; dulness in right nipple line to fifth rib, and two inches below 



190 Diseases of the Liver 

ribs. Temperature, 99°-to2°. January 13. — Slight albumen in urine; liver is larger, is 
tender to the touch and on percussion ; fine rales at base of right lung. Temperature, 
95°-io3°. 20th. — Liver excessively tender, hepatic region bulging; left lobe halfway to 
umbilicus ; dulness at base of right lung to angle of scapula ; explored left lobe of fiver 
with syringe, only obtained blood ; albumen in urine; is wasted. 21st. — Fluctuation felt 
in liver ; aspiration — this time obtained an ounce or two of thick pus. 26th. — Fluctuation 
decidedly felt ; opened antiseptically, 8 oz. of thick glairy pus, mixed with blood and 
bile ; tube inserted, followed during evening by large discharge of pus. 28th. — Has 
been very weak, vomiting ; left leg very ©edematous for a day or two, now dark blue as if 
becoming gangrenous ; sudden death. 

Post-mortem. — Body emaciated ; pus swelling up from fistulous opening ; left leg much 
swollen ; some fluid in pericardium. Heart normal. Right lung adherent to diaphragm 
by lymph and fibrous tissue ; no pneumonia ; the diaphragm abnormally raised by the 
enlarged liver below, and is adherent to it by recent lymph ; the liver has been punctured 
in the left lobe near its junction with the right on its upper and anterior surface. The 
fistulous opening enters a very irregular cavity containing pus : this cavity contains semi- 
solid cheesy material and irregular fibrous trabeculae, which give it a worm-eaten appear- 
ance ; posteriorly in the right lobe is a cheesy mass, size of an orange, beginning to 
become worm-eaten, and containing a little pus; a few other irregular cavities joining 
together : no lardaceous change. Spleen enlarged, lardaceous. Intestines matted 
together by old adhesions, the mesentery containing cretaceous masses (old peritonitis 
from suppurating glands) ; contains cicatrices of old (tubercular) ulcers ; no recent ulcera- 
tion. Mesenteric glands in places cretaceous. Left external iliac vein, ante-mortem 
clot ; kidneys congested, not lardaceous ; lungs, old scars at apices ; pulmonary arterv 
contains ante-mortem clot ; embolism. 



Hepatic Abscess 

Children occasionally suffer from multiple abscesses, the result of the 
absorption of some septic material from the region of the portal vein, or from 
some abscess in the immediate neighbourhood. Thus in one case under our 
care multiple abscesses in the liver were evidently secondary to an ulcer in 
the caecal appendix caused by a pin which had been swallowed. In a second 
case there was a large hepatic abscess communicating through the diaphragm 
with an empyema in the right pleural cavity ; and in a case of Dr. Mutton's 
hepatic abscesses were due to the contiguity of the liver with suppurating 
retro-peritoneal glands. In some cases which have been recorded abscesses 
in the liver were secondary to typhoid ulcers, and in others to the irritation 
of worms which had penetrated into the bile ducts. The symptoms consist 
in enlargement of the liver, extreme tenderness, and intermittent fever. The 
prognosis is bad. If pus is found, it should be evacuated antiseptically. 

Hydatids 

Hydatid cysts in the liver are not uncommon during later childhood, but 
are decidedly rare before five or six years of age. If the cyst is of any size and 
situated in either lobe so as to come in contact with the abdominal wall, it 
will form a smooth, rounded swelling continuous with the liver, neither pain- 
ful nor tender, elastic to the touch, or actually fluctuating. Diagnosis under 
such circumstances is easy, especially if the tumour is tapped or aspirated, 
the fluid withdrawn being of low specific gravity, non-albuminous, and con- 
taining some of the scolices or pieces of cyst wall. If the cyst occupy the 
posterior part of the right lobe, it may push the diaphragm upwards and dis- 



Tumours of the Liver 191 

charge into the lung or pleural cavity ; occasionally the cyst suppurates — in 
this case there are hectic fever, pain, and the symptoms of an abscess. 

Treatment. — Aspiration of the contents of the cyst may be sufficient ; 
the latter collapses and the hydatid may be destroyed. The operation may 
have to be repeated, as the cyst may fill up with serum. If suppuration 
occurs incision is required, and in all cases it is safer and better to open the 
abdomen, secure the cyst to the abdominal wall, and drain the cavity with- 
out any previous aspiration, even if suppuration has not taken place. 

In a case under our care, a girl of twelve years who had a large hydatid 
of the liver, the cyst was aspirated and the girl left the hospital apparently 
cured ; eighteen months after she was readmitted suffering from what appeared 
to be an empyema of the right side. It proved to be a suppurating hydatid 
cyst of the lung ; this was drained, and she finally made a good recovery. 

Tumours of the Liver 

New growths originating" in the liver during childhood are among the 
greatest rarities, though cases of carcinoma, sarcoma, adenoma, and cavernous 
tumours have been described. An interesting case of lymphadenoma of the 
liver, the only one which we have met with, was admitted to the Children's 
Hospital, under Dr. Humphreys (now of Torquay), in 1878. 

A boy aged 14 years suffered, for a month before coming under notice, with pain in 
the right hypochondriac region and wasting ; he noticed a swelling in the same region 
about two weeks before admission. When first admitted he was pale and sallow, but not 
jaundiced, the liver was enlarged, the edge reaching nearly to the umbilicus ; there was a 
large bossy swelling situated between the right costal arch and the umbilicus ; the super- 
ficial abdominal veins were enlarged and tortuous. Aspiration of the tumour yielded 
nothing but blood. He wasted, there was a hectic temperature (98°-io2°), and the 
peritoneum and right pleura became distended with fluid. He died seven weeks after 
admission, having had symptoms for three months. At the post-mortem the abdominal 
cavity contained much fluid, the right lobe of the liver was much enlarged and contained 
a hemispherical mass, which on section had the appearance and consistence of brain 
tissue ; there were some haemorrhages into its substance, and fibrous bands passed through 
it. It was surrounded by a broad zone of compressed liver tissue. There was a mass of 
enlarged glands at the fissure. The right pleura was full of fluid. Microscopically the 
new growth resembled the structure of lymphatic glands. In this case it was not easy to 
decide where the growth commenced, but, as in the analogous case of lymphadenomata 
of the kidney, there is a strong probability that it began in the lymph glands of the fissure 
and grew into and compressed the liver substance. 



92 Diseases of Nutrition 



CHAPTER XI 

INFANTILE SCURVY 

INFANTILE Scurvy is characterised by tenderness of the bones, hemor- 
rhagic stomatitis, blood effusions, purpura, and a tendency to bleed from 
various organs. 

Dr. W. B. Cheadle was the first to point out that this condition was due 
to scurvy, and to show the curative effects of orange juice and fresh food ; and 
Dr. T. Barlow has added largely to our knowledge of the subject by his 
clinical observations and post-mortem examinations. 

Infants of under six months rarely suffer from scurvy even though fed on 
improper food, and children of over two years of age are not often affected, 
probably because it is rare for them to be fed exclusively on a diet from 
which fresh food is excluded. The commonest time of life is between the 
ages of six months and two years, especially from the eighth to the tenth 
month. 

The cause of infantile scurvy is undoubtedly improper feeding, though 
other causes may be contributory. An infant has suffered from dyspepsia 
during the earlier months of its life, it has been unable to digest diluted 
fresh milk, one of the dried milk foods or condensed milk has been substi- 
tuted, whereupon the dyspepsia has improved, the infant has apparently 
flourished, until it was seven or eight months old ; then it has begun to 
suffer with pain and tenderness in its legs, or has shown other signs of 
commencing scurvy. While perhaps in this country at least tinned or pre- 
served foods of the dried or condensed sort are responsible for more infantile 
scurvy than any other foods, yet these foods are not alone in producing 
these symptoms. The continuous use of peptonised or pancreatised foods 
whether made with preserved or fresh milk will undoubtedly produce scurvy : 
and so also will malted starch or starchy foods though made up with fresh 
milk. The tendency in the use of these foods is to give too much of the 
food and too little fresh milk. Milk foods sold in bottles, known as ' human- 
ised,' and which have been over-heated in order to make them keep, are also 
responsible for a large number of cases of infantile scurvy. Scurvy mostly 
of a mild type is seen also in infants fed on freshly sterilised milk, milk and 
barley water, and also on raw milk, though this is not common. Mild scurvy 
may also be seen at times in infants taking their mothers' milk. It is not 
uncommon to find among the poorer classes of a city, infants often to four- 
teen months being nursed exclusively on their mothers' milk, and to find them 
very anaemic, with a zone of congestion around those teeth which have been 



Infantile Scurvy 193 

cut, and an ill-defined tenderness about their limbs. Such cases improve at 
once when given fresh cow's milk and orange juice. 

In a considerable proportion of cases the infants who suffer from scurvy 
have been difficult to feed, and have suffered from various forms of dyspepsia, 
vomiting, diarrhoea, pain and discomfort in the bowels. In some there is a 
history of bronchitis which in many cases seems to affect the digestion. In 
a minority of cases — at least this has been our experience — the infants who de- 
velop scurvy have been tolerably well according to their friends' account, 
but an examination is very likely to show that they are anaemic, and very often 
show signs of rickets. 

While it is certain that some dietetic error is the chief factor in producing 
scurvy, there is much about its etiology which is not perfectly plain. It is 
certain that the worst forms will be found to have had either preserved milk 
or peptonised food, and moreover they improve at once if given orange juice 
or fresh milk in sufficient quantities. But, on the other hand, it is certain that 
in some instances infants of eight or nine months old who have been taking 
30 to 40 oz. of milk a day have suffered from scurvy, and we have known infants 
of the same age given dried milk food for months without developing scurvy 
though they have suffered from rickets. Several times we have seen the 
early symptoms of scurvy arise in infants in hospital who were wasted and 
feeble, and were taking a weaker food than a healthy infant of the same age 
should have been doing on account of their weakly digestions, and this in 
spite of their diet including beef tea made with vegetables. In another case, 
that of a wasted infant of 9 months taking a mixture of cream diluted with 
milk-sugar water, the limbs became tender and the gums red, but it improved 
at once when whey was used to dilute the cream, the amount of cream con- 
tinuing the same. 

Scurvy. — Jim C, one year old, admitted to hospital January 13, weight 10 lb. 40Z. , had 
suffered much from diarrhoea and vomiting, was wasted and his subcutaneous tissues were 
cedematous ; he was given a peptonised cream mixture. January 26 he was given 12 oz. 
of cream mixture made freshly and pasteurised, containing fat 375 per cent., proteids 
175 per cent., and sugar 6 per cent. ; also 12 oz. of beef tea made with vegetables. 
February 2 he had some slight broncho-pneumonia, temperature 98°-io3° F. for a few 
days. February 9 it was noted the gums were hasmorrhagic around some teeth that were 
being cut. He was given three teaspoonfuls of orange juice daily, his food remaining the 
same ; in four or five days his gums were healthy ; his temperature was intermittent for 
some days after. 

In another case, an infant of nine months, weighing 9 lb. 6 oz. when admitted, was 
given 25 oz. of cream mixture and beef tea with some potato added ; the gums became 
haemorrhagic, and the right femur tender and swollen. The haemorrhage disappeared in a 
week after orange juice was given, and without change of diet. 

It would certainly seem that in the majority of cases, at least, infantile 
scurvy was caused by an insufficient amount or absence of an element 
which is lacking in preserved foods and present in fresh milk and also 
in orange juice ; that occasionally this element is present in insufficient 
quantities in fresh cow's milk or in human milk ; that absence of fresh air, 
life in stuffy bedrooms, depressing diseases as bronchitis and diarrhoea, 
were contributory causes. 

It is interesting to note that so acute and experienced an observer as 

O 



194 Infantile Scurvy 

Dr. Nansen looks upon adult scurvy as a disease not due to the absence of 
a certain element in the food, but rather to the presence of ptomaines in 
badly preserved milk, salt beef, or other preserved foods. He believes that 
if the preserved foods taken on a voyage are most carefully sterilised, so 
that they keep well, if regular exercise and plenty of fresh air are taken by 
the crew, and no intemperance indulged in, there will be no scurvy, and 
orange and lime juice are unnecessary. The symptoms of scurvy are un- 
doubtedly very suggestive of ptomaine poisoning, but further light is needed. 

Infantile scurvy is undoubtedly most common among the infants of the 
comfortably circumstanced classes, who are able to afford proprietary foods, 
but it is by no means uncommon among the infants who attend the out- 
patient department of the Manchester Children's Hospital ; these are among 
the poorest in the city, and are fed largely on boiled bread, supplemented 
perhaps by breast milk. Sweetened condensed milk is also a favourite food 
among the working-class population. 

Symptoms. — One of the earliest and most characteristic symptoms is 
pain, tenderness and immobility in one of the lower limbs. With this 
there is usually some hemorrhagic swelling round a tooth which has 
recently been cut or which is about to be cut. The pain and tenderness in one 
of the lower limbs may be difficult to localise if only slight, but the infant 
draws up its leg and cries when it is washed or disturbed, as in taking it up 
and carrying it about. It is perhaps thought to have rheumatism, or early 
disease of the hip is suspected. If the child has been walking or crawling, 
it will probably refuse to put its foot to the ground. When the disease is 
more marked the infant cries or screams as if in acute pain when the limb 
is handled, and indeed cries if it sees anyone coming near its cot with the 
intent of disturbing it. The hip, as we have said, may be drawn up and held 
rigidly, or it may hang down or lie motionless like a limb which is paralysed. 
In some cases it has happened that a diagnosis of infantile paralysis has 
been made. Whenever the above symptoms are observed in an infant of 
eight or nine months or more, scurvy should be suspected and the gums 
carefully examined. Appropriate dietetic treatment should at once be 
commenced. In more marked cases there will be a more or less distinct 
swelling in connection with some bone, usually the femur or tibia, or one or 
both legs may be swollen with the skin tense and shiny. There is usually 
marked weakness of the muscles of the back, so that the infant no longer 
attempts to sit up or hold up its head, but lies helpless in its cot and resents 
with cries any attempt to examine it. It is good enough if not disturbed, 
but cannot bear to be interfered with in any way. Swellings may be noted 
in connection with the bones of the upper extremity, more especially the 
humerus, or the ileum, scapula, or skull. Various haemorrhages are apt to 
take place, the commonest being from the kidneys. The urine discolours 
the napkins of a reddish brown colour, or a deposit of red-coloured 
sediment is noted in the chamber vessel, and if the urine is collected and 
examined the reactions for albumen and blood will be found. Occasionally 
there is albumen and no blood. The urine is not smoky or dark as in 
nephritis. In some cases the hematuria and stomatitis are the only 
symptoms present, or they may be the earliest symptoms. In one case 
coming under our notice, a stone in the bladder had been suspected and 



Infantile Scurvy 195 

the infant sounded for stone. There may be oozing- of blood from other 
organs, from the bowels, from the nasal mucous membranes, from fissures 
in the anus or cracks in the lips. An orbital haemorrhage is not uncommon, 
especially if the infant has a bad cough at the time and strains itself. When 
this happens the eye is pressed forwards ; the eyelid is often cedematous. 
giving the infant a peculiar appearance. In bad cases purple discolourations 
of the skin from subcutaneous bleedings are common, bruise marks being 
present round the eyes and in various places about the trunk and limbs. A 
hemorrhagic condition may be noted beneath the finger nails near their 
roots. The gums may be much swollen, may bleed easily and be very foul. 
Separation of an epiphysis and fractures of the shaft of one of the bones 
take place in some cases. The former is the more common, especially 
separation of the lower end of the femur. We have only seen one case of 
fracture of a shaft, and verified it by post-mortem examination. This was 
the case of a child of fourteen months of age, illegitimate and badly cared 
for ; it had been put out to nurse, and fed on bread and milk, though it was a 
question how much milk she had really had. Both humeri were fractured 
near the junction of the upper two thirds with the lower third. The child 
was very anaemic and rickety, and there was a blood swelling over the femur. 
At the post-mortem it was found that the fractures were oblique and had 
evidently been done some time before death, presumably by holding the 
child by its arms and shaking it for crying. The periosteum had been 
stripped off by the effused blood. The bones were markedly rickety. 

In the majority of cases when the disease is well marked the infant is 
anaemic and shows signs of rickety bones. The tip of the sternum and 
sides of the chest wall are drawn in during inspiration, the ribs are beaded 
and the epiphyses of the long bones enlarged. Not infrequently there may 
be marked signs of rickets in an infant with anaemia, and slight tenderness 
of bones. In some cases of scurvy the temperature is raised a degree or 
two, presumably as the result of some periosteal inflammation near the seat 
of the blood swellings. 

The prognosis is good if treatment is commenced before the infant has 
become too feeble and exhausted. In fatal cases death has sometimes 
supervened suddenly from cardiac failure or a haemorrhage on the surface of 
the brain. 

Scurvy is apt to run a chronic course in the absence of treatment 
directed to the cause, whereas it usually is quickly cured if the diet is changed 
in the direction of giving fresh food in some form. 

The following case illustrates some of the above remarks : 

Scurvy. — The patient was an infant (a girl) aged seven months, of middle-class parents 
(patient of Dr. Alfred Brown). We were given the following history : Healthy born, mother 
unable to nurse it ; it was consequently given Allen and Hanbury's Xo. i food, which con- 
sists of desiccated milk ; at three months of age it was given their No. 2 food, which con- 
sists of desiccated milk and maltose ; at five months of age it was given the No. 3 food, 
which consists of a malted food, to be made up with fresh milk instead of with water, as 
are the No. 1 and No. 2 ; but the mother, thinking that fresh milk would not suit, made 
up the No 3 food with No. 2 food. Thus the infant had had for seven months no fresh 
food at all, but dried milk and maltose made into an emulsion with water. The mother 
stated that the infant had thriven well, and was always looked upon as a prize baby, and 
no doubt her photograph would have formed an excellent testimonial for the food supply. 

O 2 



ig6 Infantile Scurvy 

For tWO or three weeks past she has had a bad COUgh. Two weeks before our visit, the 
nurse noticed the left eyeball was very prominent ; this appear-, to have come on suddenly, 
and so prominent was it that the nurse said she fully expected ' it would drop out.' This 
was attributed to a slight blow the infant had had on the eye from a ' teat,' or ' comforter,' 
tied at the end of a string. The eye has continued prominent ever since. She had had 
several 'bad faints.' On examination, we found the baby was large, fat, and pale; there 
was a temperature of ioi° F. She was drowsy, but was readily roused. The left eyeball 
was very prominent, and while the right eyelid closed naturally, the left ball was in part 
exposed, as the eyelids when closed would not meet. The eyelids were not puffy, there 
were no ecchymoses either on the eyeball or elsewhere. The ribs were beaded, but there 
was no tenderness about the limbs or elsewhere. She had some bronchial catarrh, and a 
persistent cough. No teeth were cut ; the gums were normal. The nurse stated the urine 
stained the napkins a brownish colour, but we could not substantiate this. She rapidly 
improved when given fresh milk and orange juice. 

Treatme?it. — In order to prevent scurvy, an infant if not fed at the breast 
should have fresh milk from healthy cows in quantities sufficient to supply its 
necessities. If in consequence of indigestion it is necessary to lessen the 
quantity of food which it takes, care should be taken to bring the quantity 
again up to the normal as soon as possible. If this cannot be done the 
infant should be carefully watched for any symptoms of scurvy such as 
tenderness of the bones or hemorrhagic stomatitis. There is no necessity 
to give raw milk ; it must be rare for children taking a full quantity of freshly 
sterilised or boiled milk to develop scurvy. The risk is far greater in using 
sterilised milk which has been heated to a high temperature and kept in 
stock for some months before being used. All dried milk foods or peptonised 
foods should be used as temporary resorts only, or should not constitute the 
sole food of the infant, and this is especially dangerous after the infant has 
passed six months of age. If any symptoms of scurvy appear ^ oz. to I oz. of 
fresh orange juice should be given daily and 30 to 40 oz. daily of fresh milk 
according to the child's age. If it is necessary to dilute the milk, whey 
should be used in preference to barley water or starchy fluids. If the child 
is over a year old and its digestive powers are good, beef tea with vegetables, 
potato broth or an egg may be added to its diet. All forms of peptonised or 
malted foods should be avoided, or excess of starchy foods, also all meat 
extracts, manufactured meat juices, and all proprietary and patent foods. 
Fresh air and sunlight are of great service. The most difficult cases are those 
in which there is chronic indigestion as well as scurvy. 



197 



CHAPTER XII 

GENERAL DISEASES 

Rickets 

Rickets is a disease that usually makes its appearance during the first two 
or three years of life ; it is characterised by chronic indigestion, deformities 
of the bones, weakness of the muscles and ligaments, and various peculiar 
nervous disorders. Dentition is retarded ; there is frequently enlargement 
of the liver and spleen. 

The commonest time for rickets to manifest itself is from the first six 
months to the end of the second year, but it is not uncommonly noted during 
the first few r months of life, and in rare cases infants may be born exhibiting 
undoubted rickety changes in their bones. During the first year or two of 
life, even in health, the digestive system is worked to its utmost capacity, in 
order that it may be able to supply the system with sufficient nutrient material, 
not only for the exigencies of daily life, but also for the rapid building up of 
the tissues which is going on at this time ; an impairment of the digestive 
powers, a weakening of the digestive ferments, or food inadequate in quantity 
or of an improper kind, necessarily means that the tissues fail to receive the 
amount of nutriment they require. This failure of the nutrient powers is an im- 
portant factor in bringing about the changes which characterise rickets. That 
a state of mal-nutrition does not always produce rickets is certain, but it is 
certainly true that it often does, and, moreover, in all cases of rickets of any 
degree of severity there is evidence of a pre-existing failure of the digestive 
powers. In some of the milder forms of rickets, when the ribs are seen to 
be beaded and the bones of the extremities deformed, without any of the 
symptoms which mark the severer grades, the child may be fat and appa- 
rently healthy, and there may be no evidence of a present or past mal- 
nutrition ; but inquiry will generally elicit some past illness or subacute 
dyspepsia, or a history of improper feeding, or some conditions which have 
tended to produce a mal-assimilation or imperfect digestion of the food. 
The deformities produced by rickets may continue to be present long after 
the acute stage has passed away. 

While we do not believe that it has been satisfactorily shown that a ten- 
dency to rickets is hereditary in the same sense that a tendency to gout is 
hereditary, yet we are far from denying that hereditary influence plays some 
part in predisposing to rickets. We believe that if either father or mother, 
especially the latter, is weakly from any cause, their children will be more 
likelv to suffer from rickets. A woman does much manual labour during her 



198 General Diseases 

pregnancy, more than her strength will really admit of, or she lives under 
unhealthy conditions : the infant is weakly, is difficult to rear, and becomes 
rickety ; we can hardly doubt that the influence of the mother's health has 
predisposed to rickets, or at least to the digestive troubles which precede 
rickets. We feel certain that weakly or premature infants may become 
rickety, even though the greatest pains and care have been bestowed on their 
feeding and bringing up. The fact that rickets may appear during intra- 
uterine life and the infant be born with beaded ribs and other symptoms of 
rickets, shows that rickets can be produced apart from any improper feeding, 
and suggests that the influence of the mother's health during pregnancy may 
be an important factor in predisposing to the disease. The influence of 
the mother's health in producing rickets is seen in large families, where 
the later children born are apt to be rickety. It happens also at times that 
first-born children are rickety, especially in those cases where the mother is 
very young. 

Does syphilis in the parents predispose to rickets in the infant ? Parrot 
asserted that rickets was the result of the syphilitic poison — that the latter 
when worn out or weakened produced rickets. Very few, even among his 
own countrymen, have accepted his views. Among the foundlings of Paris 
and other large cities where syphilis is a common disease, it may be difficult 
or impossible to say exactly what influence syphilis exerts in producing rickets ; 
in country districts, where syphilis is uncommon and rickets common, it is 
clearly seen that there is no connection between the two, or only that the 
syphilitic poison has a depressing influence on the system and so predisposes 
to rickets as it appears to do to tuberculosis. 

Dietetic hifluences. — It has been stated that infants nursed at the breast of 
a healthy mother rarely become rickety, we may say never suffer from severe 
rickets : while infants who have been artificially fed from the first, and who 
have suffered much from dyspeptic ailments, are nearly always affected. 
It is certain, however, that over-lactation is a cause of rickets. Infants who 
have been suckled at the breast for over ten months or a year frequently 
suffer from rickets. Infants who have suffered from diarrhoea, gastric catarrh, 
bronchitis, pneumonia, and especially those who have had a hard struggle 
for life, very frequently become rickety. Infants who were premature, and 
who have been reared with difficulty, are among those who often suffer. 
Infants badly fed, and those who from ignorance or necessity have been 
deprived of fresh milk and given large quantities of food in which starch has 
taken the place of fat, are exceedingly likely to suffer from rickets. That 
improper feeding plays an important part in the production of rickets has 
been shown in the rearing of the young lions at the Zoological Gardens, and 
in the feeding of puppies and other animals on lean meat. These animals 
developed rickets, but improved at once when given milk and pounded 
bones. 1 The same thing may be seen again and again among our dispensary 
patients ; a marked improvement in the symptoms following their admission 
to hospital, where a more suitable diet is given than the one which they have 
been taking. 

Now, while there cannot be a doubt that infants who have been given 
large quantities of sago, sopped bread, arrowroot, condensed milk of a poor 
1 See Cheadle, ' Rickets,' Brit. Med. Assoc. Meeting-, 1888. 



Rickets 199 

quality, or one or more of the much-advertised patent foods, early develop 
rickets, yet so also do some infants who have been brought up on fresh milk 
and water, milk and cream, and peptonised milk. The food may have been 
theoretically correct as far as quality goes, the child may have been well 
looked after, and the parents or friends are surprised at being told that it 
has developed more or less of rickets. But children who thus become 
rickety though brought up on fresh or sterilised milk have almost certainly 
suffered a good deal from gastric or intestinal catarrh, and their food has 
failed to be digested and assimilated. It is no uncommon thing to find a 
child of eight or nine months, markedly rickety, being fed with far more milk 
than it can possibly digest, passing curd, pasty stools, and suffering from 
flatulence and colic. A food in which starch or sugar has replaced fat, or 
which in other ways differs from human milk, will be only too likely to give 
rise to rickets ; but the food may have contained fat in normal quantities 
and been otherwise suitable, yet if the child suffers from chronic dyspepsia, 
and the milk food has undergone excessive lactic or butyric fermentation in 
the alimentary canal, and consequently failed to nourish, the child is likely 
to be rickety, and it may suffer laryngismus and convulsions. It seems very 
probable that some toxines, the result of indigestion, which have been 
absorbed into the blood, are the immediate causes of some of the symptoms 
of rickets. 

Hygienic and Climatic Influences. — The children of the well-to-do classes 
suffer less from rickets than those of the poor, and when they are affected it 
is in a milder degree ; the same may be said of country children as com- 
pared with the denizens of the slums of our great cities. Rickets is more 
common in damp cold climates than in warmer ones. From these facts we 
gather that bad ventilation, and absence of fresh air and sunlight, are factors 
in producing rickets. That this influence is exercised through the digestive 
organs is very probable. 

From the above remarks it is clear that we believe there are several 
factors in the production of rickets. Hereditary weakness, feebleness of the 
digestive powers, improper food, breathing vitiated air, exposure to cold 
and damp, will together, in some instances perhaps singly, produce rickets. 
Rickets abounds wherever the lower classes of the population are crowded 
together in courts and slums, where the mothers, from necessity or choice, 
are unable to suckle their infants, where fresh cow's milk is dear and of 
poor quality, and infant life is exposed to the various bad influences which 
poverty and ignorance are certain to produce. Rickets is a rare disease 
where the parents are strong and healthy, the mother able to nurse her 
infants, while taking care of her own health and diet, and is able to devote 
her whole time to the care and nurture of her offspring. 

Chemical Theories. — The older authors attributed rickets to the absence, 
or diminished quantities, of lime salts in the food, but very little observation 
was sufficient to disprove this. Others (Seeman) have supposed a deficiency 
of hydrochloric acid in the gastric juice, and that consequently the lime salts, 
instead of entering the blood, passed through the alimentary canal. Some 
have thought there was a deficiency of phosphoric acid or phosphates in the 
food, and that its absence from the blood prevented the formation of bone. 
The ' acid theory ' has also had supporters, who supposed there was an excess 



200 General Diseases 

of lactic acid in the blood, which had been formed from the decomposi- 
tion of milk in the stomach — the presence of the lactic acid dissolving the 

lime salts of the bones and carrying them out of the body in the urine. We 
confess to being completely sceptical concerning all these hypothe.se>, and 
much doubt if they explain anything as to the pathogenesis of rickets. We 
certainly think that an amount of both fat and proteids in the food below the 
normal may be one factor in producing rickets. 

Symptoms and Course. — The premonitory or early symptoms of rickets 
may be absent, or so intermingled with those of dyspepsia that it may be im- 
possible to differentiate them. In the slighter grades of rickets the first and 
perhaps the only signs of the affection are slightly beaded ribs and enlarged 
epiphyses at the lower ends of the radius and ulna. In the more severe forms 
of the disease the early symptoms are slight fever, the infant being hot and 
restless during sleep ; abundant perspiration, more especially about the fore- 
head and scalp, may then be noticed ; at this time the infant may suffer from 
convulsions and not infrequently laryngismus. His bones may be more or less 
tender, so that he cries on being moved or danced about in the nurse's arms, 
and usually some beading of the ribs can be detected. In the majority of 
cases the abdomen is habitually distended with wind, and there is mostly 
constipation, though, on the other hand, the stools may be loose and curdy. 
The child may be anaemic and the spleen may be felt to be enlarged. 

As time goes on it is noted that there is a delay in the appearance of the 
teeth ; if the first two incisors have been cut, a long interval, perhaps many 
months, elapses before the appearance of the others, and the teeth that have 
been cut are apt to become carious, from a deficiency in their enamel. The 
muscular system is almost certain to suffer, the child cannot sit up from weak- 
ness of the lumbar muscles, and the spine bows out from laxity of the liga- 
ments ; the infant does not use its limbs like a. healthy child, making no, 
or poor, attempts at crawling ; its legs are weak, it cannot bear its weight on 
them or even put them to the ground. 

Concurrently with many of these phenomena, marked changes are noted 
in the bony skeleton. The bones may be tender to the touch, and the infant 
resent being jumped about. It is quite possible, however, that this tender- 
ness is produced by slight haemorrhages, which are really scorbutic. Scurvy 
and rickets frequently are associated together. The skull early shows these 
changes, though, if rickets does not supervene till the middle or end of the 
second year, the bones of the skull may escape. There is a marked 
exaggeration of the frontal and parietal eminences, with some flattening of 
the upper surface, so that there is a sort of table-land at the vertex, the head 
assuming a more or less quadrate shape. Sometimes there is flattening of 
the occipital bone behind, so that the back of the head looks as if pressed 
in. In severe cases there are broad shallow^ grooves corresponding with the 
sagittal and coronal sutures, and consequently running at right angles with 
one another. The fontanelles are widely open and may remain so long after 
they should be closing up, and the edges of the bones where they come 
together to form the sagittal, coronal, and lambdoidal sutures are thickened. 
Instead of, or in combination with, these hypertrophic changes at the 
eminences and edges of the bones, there may be atrophy or thinning of the 
central parts of the occipital or parietal bones, which has been termed 



Rickets 



201 



cranio-tabes. These weak places can be felt by gentle pressure exerted 
with the finger on the occipital or parietal bones, of course avoiding 
the sutures, the bone perhaps bending and bowing in almost like parchment 
beneath the finger. It has been questioned to what extent cranio-tabes is 
the result of rickets, as it is present at times in undoubtedly syphilitic 
children, and also in those suffering from various wasting diseases. We doubt 
whether its connection with syphilis is anything more than a casual one, but 
it is certain cranio-tabes maybe detected in weakly infants a few months old 
who exhibit no other signs of rickets, and also in newly born infants. Whether 
it is always to be accepted as pathognomonic of commencing rickets is an 
open question ; but when present in infants over six or eight months of age it 
is almost always in our experience accompanied by signs of undoubted rickets. 

A 





Fig. 29. — Tracing of Chest Wall of a Rickety Boy 
of two years of age. 



Fig. 30.— Enlargement of Epiphyses of 
Lower End of Radius and Ulna. 
Child of eighteen months. 



Characteristic changes take place in the chondral ends of the ribs and in 
the shape of the chest, the latter being most marked in children who suffer 
from bronchitis. The ribs are enlarged or beaded where they join their 
cartilages : these may be felt or seen at a glance when the chest is exposed. 
The shape of the chest- walls is altered in consequence of the softening of the 
costal ends of the ribs ; the rigidity of the chest walls is impaired at this spot, 
so that there is a falling in of the ribs on each side, while the sternum and 
cartilages are thrust forward (see fig. 29). The sides of the chest, especially 
the region included between the fourth and eighth ribs, bend or curve inwards 
so that a more or less broad vertical groove is formed on each side of the 
chest. The angles of the ribs are often exaggerated or undergo a sharp 
bending or 'kink' at this spot. With these changes is mostly associated 
a widening of the arch which the ribs make inferiorly, and the abdomen is 



202 



General Diseases 



distended and round. If the child be watched, especially if there is any 
bronchial catarrh, the chest walls will be noticed to fall in at the groove on 
each side, and the tip of the sternum is drawn in during inspiration. All 
degrees of chest deformity may be present, from the extreme degree noted 
above, to a slight prominence or keel-like ridge in front, formed by the ster- 
num, which makes what is called the ' pigeon-breast.' The clavicle often joins 
in the deformity, its normal double curve being exaggerated. The extremities 
show peculiar changes, more especially at the lower epiphyses of the radius 
and ulna, and the tibia ; the shafts are very apt to bend and in the worst cases 
max- fracture. The lower ends of the radius and ulna are swollen, the swollen 
portion involving the irregular layer of cartilage, 
in which calcification is proceeding (see fig. 31), 
which separates the cartilage of the epiphyses 
from the shaft; in the worst cases this enlargement 
is very striking (see figs. 30 and 31). The tibia is 
usually more or less bent, the curve varying in 
position and degree ; the lower end is, however, 
most commonly bent inwards (being an exaggera- 
tion of the natural curve), so that the convexity 
is outward (see fig. 40 et seq.), a deformity which 
is produced by the child whilst sitting on the 
floor, with its legs crossed under it, shuffling 
with its legs so as to change its position. The 
deformity often takes place before the child learns 
to walk. The deformity known as ' knock- 
knees ' is produced later, after the child has 
begun to walk (see fig. 39). The other long 
bones, the femur (see fig. 34 et seq.\ radius and 
ulna, and the humerus, are apt to bend : the 
bowed humerus is sometimes produced by the 
attendants lifting the child by grasping its arms, 
just below the shoulder. If the child can sit up 
the spine is apt to become bowed, an exaggera- 
tion of the natural curve taking place in the 
cervical region, while the dorsal curve is ex- 
aggerated and involves the lumbar, so that the spine bows out backwards, 
a result largely due to the weakening of the ligaments (see fig. 38). 

It must not be supposed that all the changes in the shape of the bones 
take place in any one case, and the degree of deformity differs according to 
the severity of the case. As before remarked, the shape of the head may be 
quite normal, and only the epiphysial swelling and deformity be noted in 
the ribs and fore-arms. Sometimes muscular weakness is the symptom 
which most strikes the friends : the child is dyspeptic, has a rounded belly 
and pale face, the teeth are late in appearing ; the child, who is perhaps 
eighteen months or two years old, cannot stand or walk, and medical advice 
is sought because the parents think the legs are paralysed ; or the child is 
brought to a doctor, as it is supposed he has spinal disease, on account of 
the bowing backwards of the spine ; or the pigeon-breast is the most marked 
and striking symptom which alarms the friends. 




Fig. 31.— Section through Radius 
of case figured in fig. 30, show- 
ing exaggerated depth and irre- 
gular borders of the proliferation 
and columnar zones of cartilage. 



Rickets 203 

The phenomena noted in connection with the nervous system in rickets 
are among the most important. The whole nervous system appears to be 
affected, the nerve centres are in an unstable condition and readily discharge 
on the slightest provocation. General convulsions are common, more 
especially during the early stages of the disease ; they vary much in their 
severity, sometimes being slight and passing away quickly, but, on the other 
hand, it is no uncommon thing for a rickety child of a year, eighteen 
months, or two years to die in a few moments in a fit. Laryngismus is 
common, and indeed is almost confined to those who are rickety. Tetany 
is also common in rickety children. A hypertrophic condition of the brain, 
with a large head, is not uncommon. Rickety children are exceedingly liable 
to bronchial catarrh and broncho-pneumonia, and in them all chest troubles 
are apt to be serious. They are liable also to suffer from dyspeptic troubles, 
especially diarrhoea. 

In the severest forms of rickets the child is apt to become markedly 
anaemic, and when this is so there is usually enlargement of the spleen. It 
has been doubted if splenic enlargement is present in uncomplicated rickets, 
or in those cases only which are combined with syphilis. We certainly have 
seen cases where the spleen was enlarged, where no history of syphilis could 
be obtained. With enlargement of the spleen there is frequently a marked 
enlargement of the liver. 

The course of rickets is towards recovery, but progress is frequently very 
slow, especially in those cases where there is chronic derangement of the 
digestive organs. The child is certain to be late in walking ; instead of ' feel- 
ing his feet ' by the end of the first year, he is utterly helpless when his legs 
are put to the ground, and at the end of the second or even the third year, 
rickety children may be seen who are quite unable to bear their own weight 
on their legs. All this time, perhaps, the child is incapable of much exertion 
and is easily tired. Many dangers attend rickets on account of the weakly 
state of the child. He is especially liable to catch cold ; this may be 
followed by bronchitis and broncho-pneumonia. The latter is necessarily 
dangerous on account of the weakness of the ribs and feebleness of the 
respiratory muscles. 

Bronchitis and collapse of lung, or broncho-pneumonia, are exceedingly apt 
to be fatal when they complicate rickets. One of the effects of rickets is to 
stunt the child's growth, as well as to leave him with many deformities, which 
will be discussed in detail later on. The lowering of the child's health pro- 
duced by rickets may last for many years, but in the vast majority of cases 
the symptoms and signs of rickets, if they come under treatment, disappear, 
and the child may grow up into a healthy adult. 

Foetal Rickets. — Congenital Rickets. — In rare cases children are born with 
deformed bones, enlarged epiphyses, and beaded ribs — a condition to which 
the name of rickets can hardly be denied. Other cases have been observed 
in which the bones have been soft and deformed, but which lacked the 
characteristics — both naked eye and microscopic — of rickets. Hence some 
confusion has arisen, and the terms infantile osteo-malacia and achondro- 
plasia have been applied, as it was thought they resembled these rather than 
rickets. There can hardly be a doubt, however, that children are born 
rickety, or that they become so very shortly after birth. Such cases have 



204 General Diseases 

been observed by Bode, 1 T. Barlow,- and the late Dr. Marshall of Preston . 
In Bode's case the infant was stillborn, the mother was healthy. The infants 
head was hydrocephalic, the limbs were short and bent, the chest deformed, 
and the ribs beaded ; the pelvis was narrow. The microscopical examina- 
tion showed changes resembling those found in rickets. In Dr. Barlow's 
case there was a history of the infant being born with deformed limbs, which 
were also tender, and when seen at six weeks old the long bones and ribs 
were typically rickety, and there was a green-stick fracture of the humerus. 
Dr. Marshall's case was somewhat similar. (See CRETINISM.) 

Morbid Anatomy. — The most striking appearances in connection with 
rickets consist in the changes of the bones. In the first place, chemical 
analysis shows there is a deficiency of lime salts in their constitution, and 
an excess of organic matters. Normal bone contains, roughly, 65 per cent, 
of inorganic constituents and 35 per cent, of animal matters ; in rickets, all 
degrees of decrease of inorganic matters may take place, but in a severe and 
well-marked case the proportions are reversed, so that there is only about 
35 per cent, of mineral basis and 65 per cent, of gelatinous or organic 
matters (A. Baginsky). That there is a deficiency in calcium salts is evident 
from the spongy nature of the bone, its softness, and the readiness with which 
it 'bends ; ' while the spaces between the bony trabecular are seen to be filled 
with juicy material. If a rib taken from a well-marked case of rickets during 
the acute stage be examined, it will be found not only to be wanting in 
rigidity, but it can be bent about like a thin lath, and, if doubled up, fractures or 
'gives ' with the greatest ease ; the fracture may be only partial, or perhaps the 
ends of the bones are only held together by the fibrous and muscular tissues 
attached to them. In the same way the forearm of the cadaver may perhaps 
be bent by taking it in the two hands and applying moderate force, or it may 
' kink,' and on dissection both radius and ulna will be found to be fractured 
Other long bones may behave in a similar way if sufficient force is applied. 
The ribs, where they join the cartilages, will be noted to be much swollen : 
fractures, recent and old, may be present at the angles of the ribs and the 
lower ends of the radius and ulna where they join the epiphyses. A section can 
readily be made with a strong knife through the enlarged end of the rib, and if 
made in a direction from before backwards it will be seen in most cases that 
the pleural side is more prominent than the external side of the swelling, and, 
moreover, the enlargement is produced by the expansion of that portion of 
cartilage — the proliferation and columnar zones — in which certain changes 
are going on preparatory to the deposition of lime salts in the matrix of the 
cartilage. If a comparison be made with the end of a healthy child's rib, 
it will be seen in the latter that between the cartilage of the rib, which is 
yellowish and opaque, and the cancellous tissue of the rib, there is a line of 
translucent and bluish cartilage, about ^ inch in breadth at birth, and about 
a 1 ^ inch at a year or eighteen months old (Kassowitz) ; this line is perfectly 
regular and straight ; the breadth of it depends upon the rapidity with which 
growth is going on, which is greater during the last months of fcetal life 
and those immediately succeeding birth than it is later. In rickets the 
activity of these preparatory changes in cartilage is enormously increased, so 

1 Yirchow's Archiv, 93, Heft iii. 2 Clin. Soc. Trans, vol. xxi. 



Rickets 



205 



that the multiplication of cartilage cells takes place with great rapidity, and 
with this there is a softening of the cartilage and matrix, and a consequent 
increase in size of the proliferation and columnar zones, so that the trans- 
lucent line seen in normally growing bone is increased in breadth to 
perhaps \ inch or more, and there is a bulging or swelling in this position 
which is visible through the skin of the chest walls and corresponds to the 
junction of the ends of the ribs with their cartilages (see fig. 32). Not only 
does this normal line become a broad band of jellylike material interposed 
between the cartilage and bone, 
but the boundary between it and 
the cancellous tissue is very 
irregular and ill-defined, inas- 
much as an irregular calcifica- 
tion of the matrix is going 
on, and trabecular of calcified 
material with wide medullary 
spaces are being formed instead 
of true cancellous tissue. A 
spongy structure is built up 
which is wanting in strength 
and rigidity. Similar changes 
are going on beneath the perios- 
teum : there is a calcification of 
the inner layer, and spongy bone 
is built up instead of the firm, 
hard, compact tissue which forms 
the outer shell of healthy bone 
(see fig. 33). It is clear that, if 
the compact hard bone which 
forms the shaft of the bone is 
replaced by trabecule or arches 
of brittle, badly formed bone, 
the bone will readily bend and 
snap, and be simply held to- 
gether by the fibrous periosteum 
and perhaps some of the fibroid 
material which forms in the 
substance of the bone itself. 
The bones may remain soft and 
brittle for many months, but 
finally they harden, perhaps in a 
faulty position, and a sort of sclerosis or eburnation of bone takes place, so 
that the compact tissue of the bone is abnormally hard. Should a fracture 
take place there is a large amount of callus formed at the seat of fracture. 
In acute cases, or in those in which the hemorrhagic diathesis is present, 
bleedings large or small may be found beneath the periosteum and along 
the line of junction between the epiphysis and the shaft. 

The bones of the skull are abnormally soft and can be readily cut with a 
knife, and are much more readily bent or doubled up than are healthy bones. 




32- 



-Longitudinal section through the junction of a 
Cr 



Fig. 

Rib and its Cartilage, from a Ricket}- Child of two 
years, x 10. (Kassowitz.) PI, pleural side ; A, normal 
cartilage ; B, proliferation zone, deeper than normal ; 
C, columnar zone, depth and breadth much increased ; 
mtp, deposition of lime salts in the cartilage — ' meta- 
plastic ' ossification ; Sp. spongy tissue, with wide 
spaces filled with soft grumous material, containing 
many cells ; v, z>, v, blood-vessels. 



206 



General Diseases 



Their edges are thickened and spongy on section, much juicy-looking fluid 
exuding : the ossifying centres are usually thickened, so that the frontal and 
parietal eminences are exaggerated. In some cases prominences or bosses 
may be present on the parietal or frontal bones, near the sutures ; but it has 
been denied that these are really rickety changes, though they certainly do 
occur in rickety subjects. Instead of, or in association with, the hypertrophic 
changes just referred to, certain atrophic changes take place, the bone 
becoming thin, almost transparent, in places ; this thinning of the bone is 
chiefly present in the parietal and occipital bones. If the dura mater be 
stripped off and the bone held up to the light, it will be seen to be thin in 

places, perhaps almost as thin as 



parchment ; at these spots it readily 
yields to the pressure of the finger, 
bending in under the slightest force. 
Rickety skulls are usually large ones, 
not only that they look large in 
consequence of the thickness of the 
prominences on the parietal and 
frontal bones, but their capacity is 
increased, the brain being larger 
than usual ; it is possibly the pres- 
sure of the brain within that causes 
the atrophic changes in the bone. 

The changes found in the internal 
organs are not usually Aery marked 
unless death has taken place, as it 
not infrequently does, from broncho- 
pneumonia : then varying degrees of 
bronchitis, pneumonia, and collapse 
of lung are present. The brain is 
frequently found of large size, the 
convolutions well marked, the sub- 
stance fairly firm ; such brains are 
said to contain an excess of the 
neuroglia elements. The liver and 
spleen are usually enlarged and firm, 
and the former on section has a 
' gummy ' or more or less translucent 
appearance. Concerning the blood but few observations have been made. 
Dr. Goodhart has observed in some of his cases a deficiency of corpuscles, 
in some deficiency of colouring matters, in some the blood crowded with a 
granular detritus, and in others the corpuscles were of four or five different 
sizes. 

The most recent examinations of the blood in rickets have been made by 
Felsenthal, who examined the blood in twelve cases of rickets, varying in age 
from six months to two years. He found the number of red blood corpuscles 
nearly normal, but the haemoglobin diminished (40 to 50 per cent. — Fleischel), 
the number of white corpuscles was increased two to five times. In severe 
cases some of the red corpuscles were nucleated. 




Fig. 33.— Transverse section through the Shaft 
of the Ulna from a Rickety Child of thirteen 
months, x 10. (Kassowitz.) Showing spongy 
tissue beneath the periosteum instead of the 
compact tissue of normal bone. 



Rickets 207 

Treatment. — If rickets is due to the mal-assimilation of the products of 
digestion or to faulty digestive processes, we can hardly hope to discover 
any specific for its cure, but must direct all our efforts to secure that suit- 
able nourishment in appropriate quantities is taken, and that the digestive 
apparatus shall be in good working order. Directly the first symptoms 
make their appearance, whether they are tenderness of the bones, sweating 
about the head, or enlarged epiphyses, spongy gums, hsematuria, we should 
carefully inquire into the diet, as it is probable that the child is either not 
digesting its food properly, or it is not being properly fed. The condition of 
the digestive organs and the state of the blood act and react on each other, 
the intestinal juices are weak because the blood from which they derive the 
materials to form their secretions is weak and poor in quality, and the blood 
remains of poor quality because the digestive juices are feeble and unable to 
convert albumen into peptones, and supply the first step towards converting 
the food taken into blood. The child suffering from rickets in the acute 
stages requires albuminous and fatty foods in the most easily digested forms, 
such as cream, whey, raw meat juice, while all forms of peptonised or tinned 
foods should be interdicted. Probably it will be found that a child so 
affected is suffering from dyspepsia, the abdomen is large and distended 
with gases given off during intestinal digestion, while large masses of un- 
digested curd are being passed. The treatment must be commenced by 
cutting down the supply of curd of milk, by diluting it largely with whey 
or barley water. In the worst cases milk may have to be withdrawn entirely 
for a while, and raw or semi-cooked meat juice, with barley water, substituted. 
In older children pounded raw meat may be given. Dextrin and maltose 
in any form are preferable to sugar in excess or starches. Cream in small 
quantity will often agree, though fat in the form of cod liver oil is often more 
readily digested than any other form. A well-made emulsion may be given 
at any time, beginning, if there is much digestive disturbance, with- a few 
drops only, care being taken not to give an excessive quantity. Orange, 
lemon, grape or apple juice should be given in all cases where there is 
tenderness of the bones. Potato pulp is useful in the same condition. 

The importance of fresh air, especially sea air, in the treatment of rickets, 
cannot be over-estimated, and when the disease first declares itself a change 
to the seaside or into the country if the weather is warm enough is likely to 
be attended with the greatest benefit. In urging the friends to send the 
child out into the open air the tendency which rickety children have to 
bronchitis must not be forgotten, and the importance of warm woollen 
garments must be insisted on ; especially is this important where there is 
much sweating. If the weather is cool, the child's feet should be carefully 
wrapped up while he is out in his carriage ; a bottle of hot water at his 
feet will often prevent a chill. 

The most careful handling must be practised in severe cases, as the 
bones easily fracture or a haemorrhage may take place. The prone position 
on soft cushions in a cot or carriage is better than much nursing in the arms, 
as the limbs are easily bent and the spine bows out if the child is allowed 
to sit up much. 

Of medicines, the most important are those which assist digestion or 
correct the faulty condition of the mucous membrane of the stomach and 



208 General Diseases 

bowels, and those which aid nutrition and improve the character of the blood. 

Vomiting, constipation, dyspepsia, and diarrhoea must be treated by appro- 
priate medicines : small doses of mercury and chalk, rhubarb and soda 
pepsine or bismuth ; care should always be taken to overcome the constipa- 
tion so often present. Of tonics, cod-liver oil emulsion, or cod-liver oil in 
combination with malt extract, is by far the most important, though in practice 
it is common to find it is being given in excessive quantities and at a time 
when the digestion is enfeebled. In such cases it may be given by inunction. 
Phosphate of soda with tartrate of iron and glycerine is a useful tonic, assist- 
ing the action of the bowels and combating the anaemia so often present. 
Iodide of iron is also useful. 

Small doses of phosphorus have been given by Kassowitz, Wegner, and 
A. Jacobi, who claim for it an almost specific action. Other physicians 
have been disappointed with the results obtained by its administration. It 
may be given in doses of %fo to T £<j gr. in cod liver oil, two or three times a 
day. 

Rickety Deformities. — Distortions of the lower limbs as a result of 
rickets form a large and important group of the deformities of childhood. 
Most commonly all the long bones of the limb are affected, and there may or 
may not be distortion of the articular surfaces at the knee. In many instances 
the deformity is limited, or at least most marked either in the shaft of the 
femur, the lower third of the tibia, or the lower end of the femur. 

Curvature of the shaft of the femur takes place either with its convexity 
forwards or in severe cases forwards and outwards. There is then a wide 
space between the thighs, and the quadriceps stands out very prominently 
over the convexity of the bone ; the patient is short and stunted-looking, 
the gait waddling, and there is knock-knee or bow-leg to a greater or less 
degree. 

The whole of the shaft takes part in the curve, as is seen in fig. 34. In 
this child the deformity was extreme, and was accompanied by so much 
rotation of the lower end of the femur upon a vertical axis that the leg and 
foot faced directly outwards instead of forwards. A condition of coxa vara 
was no doubt also present in this case. Osteotomy was performed at the 
most convex part, and the limb turned round as well as straightened, so that 
ultimately the feet were natural in position (fig. 36). Sometimes the curve is 
limited to the lower end of the diaphysis. 

Rickety deformities of the upper limb are seldom of such extent as to 
interfere with the perfect use of the arms or to require operative treatment. 
Obviously this is because no such strain is put upon the arms as upon the legs 
in childhood. It is rare for even the application of splints to be necessary, 
and we have hardly ever had occasion to straighten forcibly, never to osteo- 
tomise, a rickety deformity of the arms. The distortions are most commonly 
produced by the child crawling upon the hands, and consist chiefly in bend- 
ings of the shafts of the bones. We have, however, seen a condition analogous 
to genu valgum, but reversed — i.e. instead of the normal outward obliquity 
of the fore-arm in extension, it was directed inwards so that the convexity 
of the bend was outwards at the elbow {cubitus varus) ; this disappeared 
during flexion as in genu valgum, and was probably due to a similar bony 
condition, though we could not satisfy ourselves of the exact seat of deformity. 




Fl g-. 35-— Shows the attitude habitually assumed la- 
this child, which resulted in the deformity shown in 
fig- 34- 



Fig. 34.— Rickety Deformity of the Femora, 
caused by the attitude shown in the next 
figure. There was no doubt a condition of 
' coxa vara ' in this case. 





Fig. 36.— The same child shown in the 
last two figures. The limbs have been 
straightened by osteotomy. 



Fl .g- 37-— A child aged 7 years, showing extreme stunt- 
ing from premature Synostosis, as well as various 
deformities, all the result of Rickets. The child 
could not stand alone. 



2IO 



General Diseases 



A similar condition may occur as a result of separation of the lower epiphysis 

of the humerus and irregular union. In the humerus the deformity consists 
usually in curvature with the convexity outwards. 

The rickety deformities chiefly amenable to surgical treatment are those 
of the spine and limbs ; distortions of the chest and pelvis can only be 
improved by general management of the health, and prevented from getting 
worse, though gymnastics directed especially to exercise the inspiratory 
muscles other than the diaphragm, and to increase the inspiratory capacity, 
are of great value in the treatment of rickety chests. For the pelvis, even 
if the distortion is noticed before adult life, nothing can be done except to 
prevent the deformity from being increased. 1 

The rickety spine is met with in two forms : in one there is a general 
curve convex backwards, kyphosis (fig. 38), affecting the whole dorso-lumbar 

region ; in the other there is lordosis 
(%• 37)- 

The first form is that met with in infants 
and young children before they begin to 
walk ; the other variety is usually secon- 
dary to deformities of the lower limbs, 
and is therefore most frequently met with 
after the age of two years. Lateral cur- 
vature is considered later. 

The kyphotic rickety spine is readily 
distinguished from other spinal curva- 
tures by the age of the child, the evidence 
of rickets elsewhere, the extent of the 
curve, which is large and rounded, never 
acute or angular, and the flexibility of the 
spine, so that by laying the child flat or 
holding it horizontally by its arms and 
thighs, face downwr rds, the curve speedily 
disappears. Care must, of course, be 
taken in applying this test. Finally, 
there is no pain, except in some cases 
the general rickety tenderness,- and no 
evidence of caries in the shape of abscess, 
paralysis, &c. The attitude of a child 
suffering" from rickety spine is well seen 
in fig. 38 as compared with that in caries (figs. 166, 167). 

All that is required in this condition is the general treatment of the rickets 
and recumbency, not implying by this that the child is to be kept in bed in 
a stuffy room, but that it is not to be kept sitting up on its nurse's lap, 
except for very short periods at a time. These means should be continued 
until the health is improved, and the spinal muscles strengthened by friction 

1 Chance, quoted by Noble Smith, found pelvic deformity in only 16 cases out of 600 
rickety patients, while Reeves found it in 210 cases out of 1,000. Lane believes the 
deformities of the lower limbs are all secondary to alteration in the shape of the sacrum. 
His paper in the Lancet, August 9, 1890, should be read by those interested in the mode 
of production of deformities. 




, — Rickety Curvature of the Spine. 
The Anteroposterior form. 



Rickety Deformities 



211 




and salt-water bathing. Unless neglected, the spine always recovers, and 
regains or rather develops its natural curves. 

The lordosis of rickets may be mistaken for a secondary deformity due to 
hip disease, congenital dislocation of the hips, &c, but the absence of these 
conditions is readily made Out, and other rickety deformities will be found 
present. Its appearance is seen in fig. 37, which may be compared with 
that of a case of congenital dislocation (fig. 192). 

It should be remembered that lordosis always results from some cause 
tending to throw the upper part of the spine forward in standing, such as 
caries of the upper part of the column, stiffness of the hip joints, distortion 
of the legs, or undue weight in the upper part of the body or head ; in very 
rare instances lordosis may result from caries of the spine directly, chiefly 
when the arches are the seat of disease : it is then due either to actual de- 
struction of the arches or to muscular spasm. Lordosis combined with a 
lateral curve may result from uni- 
lateral deformity of the lower limb in 
infantile paralysis, loss or shortening 
of one leg, &c. ; all these possibilities 
should therefore be kept in mind before 
it is concluded that the condition is 
simply rickety. 

As the lordosis is usually secondary, 
as already stated, to deformities of the 
legs, its treatment must be secondary 
to that of the limbs, and no special 
applications or apparatus are required. 

Where it is compensatory to an- 
gular curvature, it is, of course, neces- 
sary, and does not admit of treatment. 

Coxa vara. — A deformity of the 
neck of the femur consisting in a 
curvature downwards or depression of 
the line of the neck in relation to the 
line of the shaft of the bone, together 
with a forward curve of the neck, is not 
seldom seen in cases of very severe rickets, and produces a condition which 
has been described as 'coxa vara' — it is a 'bowing of the hip.' Since the 
neck of the femur is depressed the trochanter rises and becomes prominent, 
and the limb is shortened. Nelaton's line or Bryant's triangle will show 
displacement. The limb is also everted, and an awkward, waddling gait and 
some stiffness result. The condition is readily distinguished from ' congenital 
dislocation ' of the hip by the absence of undue mobility. Though most com- 
monly due to rickety deformity, coxa vara may result from injury, or from 
chronic or acute disease of the upper end of the femur. A certain amount of 
pain, especially after long walking, and a limitation of movements of rotation 
inward and of abduction are found. We are inclined to think that a certain 
. degree of this curvature of the neck of the femur is exceedingly common in 
cases of rickety deformity (see figs. 34 and 37). The treatment is that of the 
disease with avoidance of anything that throws stress or weight upon the 

p 2 






Wy 



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3£> 



Fig. 39. — An ordinary case of Knock-knee. 



212 General Diseases 

femoral neck. Only in extreme and firmly ossified cases is any operative 
treatment required. In such condition osteotomy of the upper end of the 
femur and rotation and abduction of the limb would be justifiable. The 
deformity may appear at any time after the child begins to walk. 

Knock-knees. — Deformity of the lower end of the femur, resulting in 
knock-knee or genu valgum, occurs in several different ways besides the 
one already described. The inner part of the shaft at the epiphysial line 
sometimes grows more rapidly than the outer (Mickulicz) ; hence the inner 
half of the shaft is longer than the outer, the inner condyle descends lower, 
the line of the knee-joint becomes oblique, and the tibia is set at an obtuse 
angle with the femur. This condition may be due to premature synostosis 
at the outer half of the growing line (Oilier and Tripier), a condition found 
so often in rickets, and explaining largely the stunted form of extreme cases. 
( Vide figs. 2)7 and 42.) Sometimes the same results follow from absolute 
overgrowth of the inner half of the epiphysis and the internal condyle as 
compared with the outer. In other instances, dependent upon the irregular 
ossification characteristic of rickets, the outer condyle does not develop, and, 
though the inner half of the epiphysis is not absolutely larger than in health, 
it is so relatively to the aborted external part. Again, the soft, ill-developed 
rickety bone, though symmetrical at one time, actually wastes or is absorbed 
as the result of pressure, and a corresponding deformity results. No doubt in 
some of these children a yielding of soft, ill-formed ligaments is the primary 
condition, and the bone changes only occur as the result of the slight obliquity 
produced by this yielding. The deformity is, however, sometimes congenital. 

In explaining the cause of the particular kind of deformity it must be 
remembered, first, that the femur is normally set at an angle with the tibia 
and not vertically upon it ; secondly, that these children often assume atti- 
tudes in which the weight of the body and limbs so presses upon certain 
parts of the shafts of the bones that they yield, and curves result. Such 
deformities are produced by habitually sitting cross-legged, as is seen in 
fig. 35, &c. Other reasons are that in certain cases congenital inequality in 
length of the limbs throws the weight of the body both unequally and 
obliquely upon one leg ; 1 and again, where the deformity has arisen before 
the age at which walking begins, the pressure of the nurse's arms and the 
leverage of the weight of the limbs themselves acting over the nurse's arms may 
produce deviation. Congenital or acquired valgus, slight degrees of infantile 
paralysis, or any cause tending to throw the weight out of the normal line, 
will in some instances prove the starting point. In all cases it is clear that, 
as the bones are soft and unduly yielding, a pressure that would have no 
effect upon a healthy bone will cause deviation in a rickety child, and that, 
when once the curve is started, it will always tend to increase more rapidly. 

It is not improbable that the irregular ossification of rickets prevents the 
normal architecture of the bone from being built up and so weakens it — i.e. 
the special arrangement of arches and struts in the cancellous tissue is 
not preserved. 

Sometimes knock-knee is due to distortion of the tibia rather than the 
femur, and it will usually be found that the upper tibial articular surfaces 

1 Reeves has laid stress strongly upon this fact. 



Rickety Deformities 



21 



are misshapen and bevelled off. This is, however, generally a secondary 
condition. 

Bow-leg-, genu varum or genu extrorsum, is a deformity which, though 
dependent upon the same general causes as knock-knee, differs from it in 
most instances in its mechanical causes ; thus it is rarely dependent upon 
a local inequality of growth in the lower end of the femur, but is usually a 
general as opposed to a local curve of both femur and tibia, and is not 
limited to the region of the knee. It is most commonly found in one leg, the 
other being the subject of knock-knee, and in such cases it will nearly 
always be found that the knock-knee has appeared first and the bow-leg 
later ; in fact, the bow-leg is the result of the knock-knee. If such a patient 
is stripped, it will be found that the axis of the trunk is directed from one 
shoulder obliquely downwards to the hip of the knock-kneed limb : then the 
line of pressure, following the axis of the thigh of that side if produced, 
would pass through the region of the opposite knee : hence yielding to this 





Fig. 40. — Shows how sitting ' cross-legged ' 
produces Curvature of the Tibiae. The 
right foot is resting on the ground. 



Fig. 41. — An ordinary case 
of Bow-leg. 



pressure produces an outward bowing of the whole of the opposite limb. It 
is true that the curve of bow-leg is not quite even, and is "usually sharpest 
at the weakest part of the leg— the lower third of the tibia ; much more 
rarely there is a true genu varum, or bowing out, mainly at the knee itself ; 
in such cases the head of the fibula is usually very prominent. 

Double genu valgum occurs when the changes in both legs begin at the 
same time and go on at the same rate ; double bow-leg results either from 
local changes exactly opposite to those of knock-knee, or, more often, is 
started by the position assumed in sitting by the child, and increased by the 
weight of the body subsequently. Thus it is common to see children sitting 
on the floor with both thighs somewhat abducted and rotated outwards ; in 
this position the limbs rest on the hips and ankles, and the knees are quite 
unsupported. The weight of the limbs then tends to bend them outwards, 
and produces bow-leg, while, if the feet are crossed one over the other, the 
curve will be most marked at the lower third of the tibia, and the leer which 



214 



General Diseases 



rests upon the other will have more of an anterior, and less of an external, 
curve than its fellow (fig. 40). 

Deformities of the tibia are more complex and difficult to explain than 
those of the femur ; besides the general outward curve already described 
as a part of bow-leg, there are found curvatures of the tibia alone, the 
femur remaining quite or nearly straight. The most common curve in the 

tibia is a sharp bend with its convexity out- 
wards and forwards at the lower third. 

Sometimes there is a projection outwards 
and backwards of the upper part of the shaft, 
just below the tuberosities, giving almost the 
appearance of a subluxation backwards at the 
knee joint. There is sometimes a condition 
of hyperextension in these patients, but the 
appearance is, we think, often due to the 
distortion mentioned (fig. 37). 

In some cases there is a bend forward and 
inwards at the middle of the shaft, or rather, 
as this is associated with gc?iu valgum, it is 
to be described as a bending outwards and 
backwards of the lower half of the leg upon 
the upper. 

It is common in severe cases of genu 
valgum to find a well-marked rotation of the 
tibia upon its vertical axis, just as already 
described in the femur, so that, instead of 
looking inwards and forwards, the inner or 
subcutaneous surface of the tibia looks almost 
directly forwards (or sometimes the rotation 
is inwards — Reeves) ; the upper third of the 
tibia may look almost directly forwards, the 
lower third inwards and backwards. In such 
cases the inner border of the tibia is very 
strongly marked, forming a prominent ridge 
somewhat spirally twisted, ending below at 
the convexity of the forward curve, and above 
at the inner side of the internal tuberosity 
(fig. 42). In many cases, especially in those 
of long standing, whether this inner border is 
well marked or not, there is a prominent 
spur-like buttress of bone developed below the inner tuberosity at the 
insertion of the internal lateral ligament ; this spur, the existence of 
which was, we believe, first pointed out by Mr. Clement Lucas, is pro- 
bably the result of ossification of the ligament as a result of strain and 
irritation, somewhat as in the case of ' rider's bone ' and other instances 
of bony overgrowth at the attachment of greatly used muscles. The 
prominent ridges, as stated by Mr. Noble Smith, are most marked when 
the disease is arrested and the stage of hyperostosis has come on. 
Sometimes there is a flat surface of bone running up from the spur to 




Fig. 42. — A case of severe Rickets, 
showing most of the commoner de- 
formities, as well as dwarfing from 
Synostosis. 



Rickety Deformities 215 

the inner condyle of the femur (Macewen) ; in severe cases this is very 
striking", and the spur reaches down far below the direct insertion of the 
ligament. Two other conditions associated with these deformities require 
notice : one is that the patella in severe cases of knock-knee tends to ride 
outwards upon the external condyle, and even to be dislocated quite to its 
outer surface during flexion of the limb. This is the result partly of deficient 
size of the external condyle, and partly of the bony curves, so that the 
quadriceps, acting in a straight line, does not make traction in the axis of the 
bones. The patella may also sink so deeply into the intercondylar notch 
in flexion that its position may be marked by a depression. The other con- 
dition referred to is the direction and arch of the foot. In knock-knee the 
foot would naturally point outwards in consequence of the alteration in the 
axis of the limb, while in bow-leg the toes point usually, though not always, 
forwards or slightly inwards. Besides this, there is in some instances flat- 
foot more or less severe. It has been asserted that flat-foot is really the 
cause of genu valgum, but that this is not so in by any means most cases is 
readily shown. Very often, instead of flat-foot, there is a condition of pes 
cavus, together with a peculiar spasmodic contraction of the great toe. Both 
the cavus and the spasm of the flexor of the great toe are evidently due to 
the efforts made to obtain a firm grip of the ground in order that the 
instability caused by the knock-knee may be counteracted. Sometimes the 
great-toe spasm exists Avhen flat-foot is present, and it is seen in bow-leg and 
curve of the tibia alone as well as in knock-knee. The foot is inverted to 
prevent strain upon the internal lateral ligament of the ankle, the flexors of 
the toes, and tibialis posticus, as well as to allow the foot to be placed flat 
upon the ground ; this tends to bring the bearing point upon the outer side 
of the foot and to remove the ball of the great toe from the ground ; then, 
to compensate for this, the toe is flexed so that the last phalanx may take a 
share in the support of the body. These points are to some extent shown 
in the preceding figures. 1 

To summarise, then, the following deformities may exist in the lower 
limbs as a result of rickets : 

1. 'Coxa vara' or a curvature of the neck of the femur downwards and 
forwards, or less often backwards. 

2. Curvature of the shaft of the femur, with its convexity forwards, or 
forwards, and outwards throughout its whole length, together with rotation of 
the lower half upon the upper through a vertical axis. 

3. Diaphysial overgrowth on one side of the growing line, absolute, or 
relative from synostosis of the other halt. 

4. Overgrowth of either condyle, with absolute or relative smallnessofthe 
other condyle. 

5. Curvature of the lower third of the femur, with its convexity inwards 
(according to Macewen the commonest cause of genu valgum). 

6. Curvature of the shaft of the tibia as a whole, the convexity being 
directed outwards. 

7. Curvature of the upper part of the tibia, so that the convexity is 

1 Macewen believes that flat-foot occurs in children before walking, but that on walking 
the cavus and toe spasm are developed. 



216 General Diseases 

directed backwards and outwards : possibly this distortion is sometime- al 
the epiphysial line. 

8. Curvature of the shaft of the tibia at the middle, the convexity being 
directed forwards, or forwards and inwards. 

9. Curvature of the shaft of the tibia at its lower third, the convexity 
looking forwards and outwards, more rarely directly forwards. 

10. Rotation of the tibia spirally upon a vertical axis. 

1 1. Overgrowth of the ridges on the tibia, especially the internal border 
and the region below the inner tuberosity ; similar outgrowths sometimes occur 
about the internal condyle and along the concavities of the curves of the femur, 
as well as in the neighbourhood of any of the epiphysial lines. 

1 2. Dislocation of the patella outwards. 

13. Flat-foot, pescavus, spasmodic contraction of the flexor longus pollicis. 

14. The muscles and ligaments on the concavity of the curves in either 
direction may be contracted and shortened, those on the convexity stretched 
and weakened. 

15. The pelvis and lower limbs may be stunted as a whole from lack of 
development or premature synostosis. 

Late Rickets. — Though perhaps hardly coming into the category of 
children's diseases, mention must be made of the so-called ' late rickets/ or 
' rickets of adolescence,' in which deformities, knock-knee, flat-foot, and. 
more rarely bow-leg, come on between the ages of twelve and twenty years 
or thereabouts, the deformity being a bony and not merely a muscular or 
ligamentous one in the case of knock-knee. 

This condition has been attributed to a disease allied to osteomalacia ; 
it has also been described as relapsed rickets, and by Mr. Lucas has been 
said to be associated with masturbation and albuminuria. As to these alleged 
causes we may say that it is not often, we think, relapsed rickets, for we have 
seen many instances where there was no evidence that rickets had ever 
existed in childhood. It is not osteomalacia, for the patients never die of the 
disease, the process becomes arrested, and it does not occur under the con- 
ditions met with, nor attack the parts affected in osteomalacia. It is certainly 
not due to, nor even associated with, either albuminuria or masturbation in 
by any means all instances. We have examined such patients a good many 
times, and in only one was there even a trace of albumen in the urine, and, 
as is well known, this may occur quite apart from the condition under dis- 
cussion ; in none of our cases was there any evidence of masturbation. It 
is, we believe, due simply to weak health, bad air, long standing, poor food — 
in short, to bad hygienic conditions at a time when growth is active in the 
limbs — in fact, mainly to those causes which produce rickets in earlier life; 
but in consequence of the greater strength of the skeleton and its more com- 
plete ossification, as a rule it only produces deformity in those parts on which 
the greatest strain is thrown ; in some cases there is well-marked enlarge- 
ment of the epiphyses, of recent appearance, and not dating back to the 
usual time of rickets : this we have seen, and other cases have been recorded 
where both the external and microscopical appearances were identical 
with rickets. 1 The affection is, we think, best described as late rickets ; it 

1 Vide Clutton, St. Thomas s Hospital Reports, 1884, and Mickulicz referred to in 
Macewen's book. 



Rickety Deformities 217 

furnishes a large number of the patients upon whom osteotomy in adult life 
is performed. 1 

Summary. — A child, then, suffering from knock-knee the result of rickets 
will present the following appearances in addition to evidences of rickets in 
other parts. As he stands the femora will be seen to project markedly for- 
wards and outwards, the extensors of the thigh being firm and prominent. 
There is often some flexion of the thighs upon the pelvis, and of the legs upon 
the thighs ; and secondary lordosis, resulting in a peculiar doubled-up and 
crouching attitude. The legs are set at an obtuse angle with the thighs, the 
patellae are displaced outwards, and the internal condyles of the femora look 
forwards and inwards, instead of directly inwards ; the w T hole limb is in fact 
rotated outwards. The tibial ridges are unduly developed, and there is a 
spiral twist in the leg. The feet are directed outwards, though the toes are 
somewhat adducted, and spasmodically grasp the floor, the flexors being 
strongly contracted, especially that of the great toe : the arch of the foot is 
exaggerated, or may, on the other hand, be lost. In walking, one knee passes 
in front of the other, in severe cases to such an extent that the appearance is 
that of a person walking cross-legged. The patient's height is much less 
than it should be from the actual length of the limbs, and he is easily tired 
and complains of aching of the legs, especially on the inner side of the 
knee if the deformity is increasing. In other instances, however, though 
much deformed, the child is as active and sturdy as his fellows, and makes 
no complaint of pain or tiredness ; when this is so, the distortion is usually 
not increasing. On examining the knees more closely it is found that 
on flexion of the joint the leg can be brought into the same line with 
the thigh — a result due to the slipping back of the tibia from the more promi- 
nent part of the condyles to the posterior surface. The internal condyle 
can be felt to be larger and to descend lower than the external, so that if 
the limb is placed in such position that the lower borders of the two condyles 
are on the same level, the axis of the femur is much more oblique than in 
a healthy limb (Reeves). The patella in extension keeps its natural position ; 
while in flexion in severe cases, as already noticed, it slips outwards and 
leaves the intercondylar notch plainly perceptible, the appearance being much 
that of fig. 225. On attempting to straighten the limb during extension this 
will be found impossible, though a little lateral movement may take place, 
and the tendons of the biceps and the ilio-tibial band of fascia will become 
very tense. The head of the fibula is sunken, and concealed deep within the 
angle between the tibia and femur. The seat of pain and the tubercle at the 
insertion of the internal lateral ligament have been already alluded to. 

The degree of deformity present varies greatly, but never reaches nearly 
the extent in children that it does in adults ; in an adult case we have seen 
the leg almost at a right angle with the thigh, and in another that we 
operated upon there was 19^ inches between the malleoli when the inner 
condyles were in contact. In double genu valgum ten inches deviation 
would be an extreme case in a child, and five inches a severe one. 

In measuring the deformity it is best to lay the child upon a flat, hard 

1 Mr. Reeves in Practical Orthopcedics gives an elaborate account of the causation of 
these deformities, which we are not altogether able to follow. 



2 1 8 General Diseases 

surface ; the legs must then be fully extended and rotated inwards until the 
front of the lower end of the femur looks directly forwards ; the two internal 
condyles are then to be put just touching one another. A vertical line is then 
drawn through the umbilicus and centre of the pubes downwards to the level 
of the malleoli, and on measuring the distance from the inner malleolus on 
each side to the vertical line the amount of deviation will be ascertained. In 
double genu valgum the line will, if the limbs are symmetrical, pass through 
the point of contact of the condyles, while in bow-leg it will lie far within the 
arc of the upper part of the limb, but may pass to the outer side of, or through 
the ankle. 

Knock-knee in children does not always depend upon rickets, and it is 
important to recognise this fact. It may simply be the result of lax liga- 
ments without any primary or even secondary alteration in shape of the 
bones ; thus a child may have marked genu valgum while standing up, but 
on lying down it may be possible to bring the legs perfectly straight, and to 
again produce the deformity by steadying the thigh and abducting the leg ; 
a distinct gap will then be felt between the femur and tibia on the inner side, 
and lateral rocking may be easily shown. In such patients the deformity 
may after a time become permanent from stretching of the muscles and 
ligaments on the inner side and contracture of those on the outer aspect. 

A similar deformity in one of our patients was the result simply, apparently, 
of hysterical contraction of the muscles on the outer side, with weakness of 
the internal set, '■muscular spasm ' (Guerin). 

Treatment of Rickety Deformities. — The degree of deformity, the age of 
the patient, and the state of the disease, whether stationary or getting worse, 
and the amount of care and trouble that can be bestowed upon the child, are 
the points to be considered in the treatment of these cases. Thus it is useless 
to attempt to treat by instruments or splints a very severe case of distortion, 
while, on the other hand, it is rarely necessary to perform osteotomy upon a 
child under three years old because the application of splints with or without 
previous forcible straightening, if it is a case of curve of the tibia alone, will 
usually suffice for a cure. Again, if the deformity has been stationary for some 
time and it is probable, therefore, that the post-rickety sclerosis of bone has 
taken place, it is useless to think of straightening the leg without operation, 
while if the curvature is getting worse, it is probable that the bones are still 
sufficiently soft to yield to pressure. Besides these considerations comes the 
very important one of the amount of care and time that can be bestowed 
upon the child ; it is not only justifiable, but necessary, to perform osteotomy 
upon many children who could be straightened perfectly well without operation 
if they could be seen frequently by the surgeon, be kept off their legs, and 
their splints properly applied, but who are neglected, allowed to get about 
anyhow, and their splints are applied wrongly or not at all. In such cases it 
is mere waste of time to do anything short of operation ; hence we have 
frequently osteotomised or forcibly straightened the limbs of children between 
two and four years old, and we entirely disagree with the view that it is bar- 
barous to operate upon young children who could be straightened without 
operation if it were possible to give all alike the same care and time. At any 
rate, it is practically a choice between their remaining crooked and osteotomy 
or fracture. The general constitutional treatment of rickets has been already 



Rickety Deformities 219 

considered elsewhere. The local treatment consists in operative and non- 
operative means. 

Treatment without Operatio7i. — In a young child with the deformity in- 
creasing, but not very severe, who can be well looked after, the treatment of 
knock-knee consists in forbidding him to stand at all, in bathing and rubbing 
the limbs well to improve their circulation and muscular power, and in using 
firm, steady traction in the direction of straightening the limb, as if to break 
the leg across the knee, for ten minutes at a time night and morning, such 
force as can be borne without pain being employed, and care being taken that 
the limb is fully extended. For the rest of the 
day and at night the child should wear a light, 
slightly hollowed, straight splint, long enough to 
reach from the top of the trochanter to just below 
the sole of the foot. This splint should be fixed 
to the upper part of the thigh and the lower part 
of the leg by inelastic webbing straps, while over 
the prominence of the knee an elastic strap should 
be applied to draw the knee outwards against 
the splint ; we prefer this plan to bandaging only. 
As soon as the child's health is improved, or if the 
case is very slight, a shorter splint may be em- 
ployed and he may be allowed to walk about 
wearing it. A light iron splint such as Thomas's 
may be used instead of the wooden one. 

If the distortion is at all severe, a practical 
difficulty will be met with in applying and keeping 
on the wooden splint : it will be found that the 
splint slips round to the antero-external aspect 
of the limb instead of remaining at the outer 
side : when this happens no traction is exerted 
upon the knee, and the splint is useless. In 
such cases, if the iron cannot be obtained, a 
back splint rather broader than the limb and as 
long as the outside one should be first applied, 
and then the outside splint put on with its edge 
resting against the edge of the back splint. The 
two splints can be joined together so as to make a 
single half-box splint — apian first used, we believe, 
at the Victoria Hospital, Chelsea. We have 

devised a splint which we find efficient and satisfactory (fig. 43). It is 
a combined back and outside splint, with a footpiece set at an angle such 
that the outward rotation of the limb is prevented, and, by the use of 
elastic webbing straps, the knee is drawn outwards towards the outside splint. 
The letters indicate the position of the webbing straps of which that at E 
should be elastic. We are indebted to our friend Professor Young for the 
drawing from which the figure is taken. Thomas's knee splint may 
also be used for these cases ; its advantages are that the child can get 
about from the first, and that elastic traction can be employed with it ; its 
disadvantages that it is somewhat troublesome to get made correctly, except 




220 General Diseases 

at the price of a guinea, and that it is somewhat difficult to prevent rotation 
in it. Many other forms of appliance may be bought, but those mentioned 
are in our opinion the best. Whatever splint is employed, complete 
extension of the limb is necessary for the apparatus to produce any effect.' 
For bow-leg it is only necessary to apply the splint on the inner side instead 
of the outer, and it is much easier to manage, since there is little tendency 
to rotation of the splint. Lateral curve of the tibia is treated in the same 
way, but the splint need not reach above the knee ; the anterior curve 
requires a back splint with a foot-piece, and is more troublesome to manage, 
pressure being difficult to apply without causing pain at the heel. A simple 
anterior curve is, however, a much less serious deformity than the other, and 
is much more prone to improve without apparatus. 

Operative Treatment of Rickety Deformities. — Operation is required in 
patients in whom the deformity is severe, in those who have recovered from 
the rickety process and whose bones are sclerosed, and in those who cannot 
be well looked after or submit to prolonged treatment. 

Operative measures are of three kinds : fracture after partial division of 
the bone with saw or osteotome, forcible straightening without external wound, 
and straightening after tenotomy, &c. In cases of curvature in the shafts of 
the tibia and fibula at the lower part of the leg in young children, before 
sclerosis has occurred, we consider forcible straightening a good and simple 
plan, resulting in a green-stick fracture just at the curve. It is, in any case 
suitable for it, easily done by taking the child's limb in one hand just above, 
and in the other just below, the deformity, taking care to have hold of the 
tibia and fibula, and not of the foot, otherwise the strain would come upon 
the ankle joint ; the limb is steadily and forcibly bent straight by the hands ; 
a certain amount of jerking is, however, sometimes useful. Tenotomy and 
subsequent straightening in cases of genu valgum we look upon as highly 
objectionable : it weakens the joint and only temporarily straightens the limb.- 
As to forcible straightening in cases of genu valgum, we have strongly 
condemned it in former editions, but having asked Mr. Murray of Liverpool 
to give his experience, he writes thus : 

' During the last three years I have practised somewhat extensively a method of treat- 
ment that was recommended by Professor Ogston at the Glasgow Meeting of the British 
Medical Association — viz. immediately and forcibly correcting the deformity,' and then 
applying the splints. I have thus straightened more than four hundred knock-knees, and 
have every reason to be well satisfied with this line of treatment. But in speaking of 
osteoclasis for genu valgum, I wish it to be clearly understood that I practise it chiefly as 
a substitute for splints, and consequently refer only to the treatment of this deformity as 
it occurs in quite young children, that is to say, in children under five years of age, or in 
those a year or two older who are markedly rickety. 

' Many surgeons, I believe, practise osteoclasis for curved tibice, but comparatively few 
do so for knock-knee. .The objection, it is said, being that in so doing you produce 
a separation of the lower epiphysis of the femur, and so may interfere with the subsequent 
growth of the limb. Now I have on several occasions forcibly straightened a knock-knee 
on one side only, and have examined the children eighteen months afterwards, and found 

1 Hueter treats genu valgum by simple flexion, and Little thinks well of it, but suggests 
sitting a la Turque as useful. 

2 Vide Lannelongue, Le Bull. MM. ; also Annals of Surgery, January 1888. 



Osteotomy 221 

absolutely no difference in the length of the limbs. And further, at the time of operation, 
I examine for the seat of fracture, and find that it almost invariably takes place at a point 
where the lower end of the femur joins the shaft, and quite an inch above the epiphyseal 
line. 

' My hands are the only osteoclasts I have ever used, and in forcibly straightening 
a knock-knee (say that of the right side), standing to the right of the patient, the child of 
course being under chloroform, I grasp the thigh firmly with my left hand about two 
inches above the patella, using my index finger supported by my other fingers as a 
fulcrum, and hold the thigh perfectly steady with this hand ; then, with the right hand 
grasping the leg just above the ankle, gradually straighten the limb, the knee joint being 
kept over-extended the whole time. 

' After osteoclasis I put the limb in plaster of Paris, which is kept on for a month ; the 
plaster is then removed and the child kept off its feet for a further period of six weeks, 
after which it is allowed to run about, constitutional treatment being, of course, adopted 
from the first. 

' There is no doubt that in children over four years of age considerable force is some- 
times necessary ; if, however, in attempting to forcibly straighten a crooked bone one has 
to use so much force as to render it uncertain where the fracture will take place, then you 
had better desist and perform an osteotomy. ' 

Mr. Murray, in addition to writing the above account, has been good 
enough to come over and show us his modus operandi, and we must admit 
that, strictly within the limitations of age and rigidity of bone that he 
mentions, and provided his exact method is followed, we are convinced that 
the operation is safe and practicable ; but Mr. Murray's method must be 
absolutely followed, and the exact site of the fracture determined ; it is not, 
moreover, every surgeon who has Mr. Murray's skill. Other methods of 
treatment do not require further notice. 

Osteotomy. — The general principle of an osteotomy is to partially divide 
with a saw or chisel the shaft of the bone in the neighbourhood of the 
deformity through a small wound, then to complete the fracture, straighten 
the limb, and treat it like an ordinary compound fracture. 

Of the various operations devised by Ogston, Macewen, Chiene, Reeves, Schede, and 
others, for remedying genu valgum, in our experience that of Macewen and the section 
of the femur above the condyles by means of a saw from the outer side are the best. This 
plan was, we believe, first employed by our colleague Prof. T. Jones. We occasionally 
do an Ogston' s operation, but supracondyloid osteotomy with a fine Adams' or keyhole 
saw is, we think, the most generally useful method. Ogston's plan should be limited to 
those cases where the deformity is entirely due to condylar overgrowth. It is very seldom 
employed. In the case of osteotomy of the tibia we prefer to saw through the tibia and 
fracture the fibula forcibly, or, if that cannot be readily done, we divide the fibula with an 
osteotome through an incision on the outer side of the leg. 

After straightening the limb we put it up in a back and side splint, inner or outer, 
according to the deformity, or in a Macewen' s splint, and leave it for a week ; at the end 
of that time we take it down and mould it accurately into position under chloroform : 
the callus is soft and moulds easily ; the limb is then ready for a plaster of Paris splint, 
which should be kept on for three or four weeks and then taken off, and the limb well 
rubbed, the joints flexed, and then the splints or the splint (fig. 43) replaced for another 
week ; after that the child may be allowed gradually to put his weight upon it. In heavy 
children an extra week snould be given, and a light wooden splint worn for another month 
or so. It is a good plan to put on a Thomas's knee-splint after the first month, or even 
sooner. 

In severe cases of tibial curve, especially of anterior curvature and in some of those 
at the upper part of the leg, the deformity cannot be remedied by a simple section, but 



222 General Diseases 

requires the removal of a wedge of bone-; this is a very much more serious operation, and 
one that we think should not be performed for the anterior curve alone, for besides its 

severity it does little to remedy the distortion unless a great amount of bone is taken away, 
and the tendo Achillis divided as well. This anterior curve is also much less important 
than the lateral one, and has more tendency to improve without operation. If osteotomy 
is required in such a case, the oblique section of Gowan is probably the best. 

Osteotomy is a simple operation in most cases, but it has its dangers and its mortality. 
The popliteal artery has three times been wounded, severe bleeding has also occurred from 
the anastomotica magna, death has followed in some few cases, and gangrene of the leg 
in one at least — a case of our own, in which we removed a wedge from the upper part of 
the tibia. In this, our only serious casualty, no vessel was wounded, but either from 
pressure of the bones in their altered position, or from the splints being put on too tightly, 
the limb had to be amputated subsequently. There is no comparison between simple 
section and excision of a wedge in severity. For details of the various operations we must 
refer to the orthopaedic and general surgical works. 

Drilling holes in the bone and subsequent fracture, with modifications of this plan, 
have, we think, no advantages over the saw and osteotome ; which of these is used is 
nearly a matter of indifference. 

Multiple osteotomies, i.e. section of femur and tibia at one or more points, are some- 
times required ; when this is so we prefer to do one at a time on each limb, though Mac- 
ewen has many times done several with perfect success. Deformities of the fibula alone 
from rickets are never important. 

Osteotomy of the femur with a saw from the outer side is best performed by placing 
the limb upon a sand pillow, with the knee slightly flexed, and making a puncture with a 
large tenotome on the outer side of the limb, just in front of the border of the tensor 
vaginas femoris, and a finger's breadth above the level of the adductor tubercle. The 
knife is then carried across the limb, keeping as close to the bone as possible, taking care 
not to thrust it through the skin on the inner side. In this part of the incision the blade 
should be held flat, i.e. in the same plane as the surface of the femur; as soon as the 
inner side of the limb is reached the knife is turned with its edge against the bone and 
withdrawn. It should during withdrawal be gently pressed against the bone so as to 
divide the periosteum and form a track for the saw. As soon as the knife is taken out of 
the wound the narrow saw is thrust sharply with a jerk into the skin wound and its point 
made to strike the femur ; it is then carried readily over the front of the bone and its 
point felt beneath the skin on the inner side. The limb is well steadied and the bone 
sawn ; care being taken to saw at right angles to the axis of the femur. In sawing, the 
hand should be tilted, so as to divide mainly the outer and front parts of the shaft, until 
nearly the whole thickness is sawn through. It is a matter of experience how far to saw 
— usually about two-thirds of the way through is sufficient ; a useful guide is the depth 
of the saw from the front of the bone as felt through the soft parts. When the bone is 
nearly divided the saw- is withdrawn, the thigh steadied by the hand nearest" the patient's 
trunk, and the limb bent inwards by adducting the leg with the other hand. The bone 
sometimes snaps sharply and sometimes yields : in the latter case sclerosis has not 
probably gone so far, and the fracture is more or less green-stick. One of our house 
surgeons remarked that the patient had less pain after these yielding fractures than when 
the division was complete, no doubt because there was no complete separation and less 
mobility of the fragments. 

Should the saw have been withdrawn too soon, and it is found impossible with reason- 
able force to fracture the limb, it is usually easy to reintroduce the saw- and divide the 
bone further : the groove already made is usually found without much trouble ; failing 
this, the best plan is to enlarge the opening and divide the bone with an osteo- 
tome. 

Section of the tibia is done in the same way, the puncture being made over the anterior 
border of the bone at the line of greatest curvature. It is usually possible to fracture the 
fibula ; if not, it should be divided with an osteotome through an incision over it. Mac- 
ewen's operation we need not describe, as for general use we prefer the method already 
mentioned, but we may say it consists in incomplete section of the femur with a graduated 



Lateral Curvature of the Spine 223 

osteotome from the inner side, through an incision in the soft parts. His guides are ' a 
line drawn a finger's breadth above the level of the upper border of the external condyle, 
and a line drawn parallel to and half an inch in front of the tendon of the adductor 
magnus.' The point of intersection of these lines is to be the centre of the incision. In 
none of these operations is any ligature or suture required, and antiseptics should be 
rigidly carried out. The wound in the soft parts is healed usually in a week, or a point 
of superficial granulations alone remains, and it is only occasionally that the dressings 
require changing from oozing of blood. It is well to squeeze all the blood out of the 
opening before putting on the dressings. 

The deformity resulting from non-apposition of the fragments after these operations 
gets modelled down after a few months just as in a fracture. Oblique section of the bone 
as in a splice, a plan suggested by Mr. Gowan, is sometimes worth trial ; it causes less 
immediate deformity, but is somewhat more difficult to manage. 

lateral Curvature of the Spine. — This affection in its most common 
form is a disease rather of early adult life than of childhood, being seldom 
found before puberty, hence only the more important features will be con- 
sidered here. There are, however, certain forms of scoliosis that belong to 
childhood more particularly : such are the rickety lateral curvatures and those 
due to empyema or unilateral limb-shortening, as well as, of course, the con- 
genital cases. It must be remembered that in infants the normal curvatures 
of the adult spine do not exist. 

It is now well recognised that the deformity is a compound one, that there 
is never a pure lateral curve without rotation, nor pure rotation without a 
lateral curvature, although it may in some cases require close observation to 
verify this, and the more so that rotation conceals to a greater or less extent 
the deviation of the spinous processes by bringing them nearer the middle 
line. 

As soon as any lateral bending in one segment of the spine occurs, two 
things necessarily happen if the child maintains the erect posture : first, 
compensatory curves must take place in the other parts of the spine to 
balance the primary curve and maintain equilibrium : next, the obliquity of 
the articular processes, and in the dorsal region the powerful rotation action 
of the ribs when they are approximated, must result in rotation of the 
vertebras upon a vertical axis. 1 Hence in a case of lateral curvature we 
almost always see compensatory curves in the opposite direction, and in- 
variably more or less rotation ; the term rotato-lateral curvature is therefore 
the more exact title. Scoliosis is convenient as a short synonym. Scoliosis 
in children may be the result of— 

1. Congenital malformation of the spine, in which imperfect segments 
of vertebral bodies are intercalated on one side of the spine only. (Bland 
Sutton, ' Med.-Chir. Trans.' 1884.) 

2. Congenital deficiencies in the limbs of one side, so that the action of 
the muscles and the weight of the normal limb are unbalanced. 

Occasionally scoliosis is secondary to the form of congenital torticollis 
which is due to malposition in utero. 

3. Shortening of one leg from any cause : for instance, a flexed, anchy- 
losed hip or knee gives rise to shortening and compensatory scoliosis. 

1 Judson of Xew York attributes the rotation to the fact that the ribs are attached to 
the spine behind the bodies — the latter, as it were, are free in the thoracic cavity, and there- 
fore liable to rotate, while the spines form part of the thoracic wall. 



224 



General Diseases 



4. Imperfect development or sinking in of the chest-wall on one side, as 
in atelectasis or empyema. 

5. Muscular and ligamentous weakness combined with faulty attitudes. 

6. Rickets. 

7. Caries, especially if one side of the bodies only is involved. 

Various other types of scoliosis have been described, but they may all be 
practically grouped under one or other of the above heads. 

The mode of production of rotato-lateral curvature by the above causes 
is obvious except in cases of Group 5, of which a word or two more must 
be said. It is usually stated that this form of scoliosis is a disease of the 
upper classes, and is found in girls who loll about or sit in ungainly attitudes 
for long hours, writing or working, during their most active period of de- 
velopment, while at the same time no sufficient exercise is given to their 
muscles. While it is true that weak spines or slight degrees of curvature 
are often thus produced, the disease is common enough among the poor, 
and, as it is usually neglected in its earlier stages, is seen in much worse 
decrees. It is also not rarely found in muscular, well-developed people in 
early adult life. It is, moreover, at times produced in young girls by carry- 
ing heavy babies or other burdens too great for them. 

The whole spine should in all cases be carefully examined with the patient stripped, 
and the back should be inspected in different positions of curvature and of the limbs, 
the course of the spines and the level of the scapulae and iliac crests being noted. 

If a weak or tired spine is examined with the patient stripped and 
standing or sitting upright, it will perhaps be seen at first to be held fairly 
straight, but often after a minute or two the weight is thrown to one side, 
the lumbar vertebrae curve with their convexity towards that side, and a 
compensatory dorsal curve appears with its convexity to the opposite, 
usually the right, side, while a slight alternating curve in the cervical region 
is sometimes readily seen. At the same time flickering contractions of the 
spinal muscles as they become tired are often visible. In an early case all 
these bends can be straightened out by an effort of the patient, or by bending 
forwards or by lying down. If, however, the patient is neglected the curves 
tend to become permanent, for the weak muscles become contractured on the 
concave side, the ligaments become shortened, the intervertebral discs thinned 
and compressed, and the shape of the vertebral bodies and articular sur- 
faces at last altered. But while this is going on the vertebrae rotate upon a 
vertical axis so that the bodies come to face towards the convexity of the 
curve, and the ribs become bent in such a way that there is a sharply convex 
bend backwards close to their angles on the same side : this produces a 
prominence also on the convex side, while in front, in order as it were to 
reach the sternum, the ribs are usually more or less flattened and straightened 
out. The converse of all this takes place on the opposite side of the spine. 
There is still a further change resulting from this : the scapula on the convex 
side is pushed out by the bulging ribs and projects backwards, while it is raised 
or lowered above the level of its fellow according to the exact seat of the 
curve ; this is so marked that 'growing out of the shoulder' is usually the 
first-noticed sign and the popular name for the affection. The scapula on 
the concave side also often projects sharply backwards and towards the mid- 



Lateral Curvature of the Spine 



225 



line, since it cannot rest evenly against the flattened chest wall {vide fig. 44). 
A projection of the hip on one side or the other according to the curve will 
also be noticeable. 

All degrees of deformity may be met with, from the mere weak spine, with 
no permanent curves, but with a tendency to collapse in any direction, to 
deformity, where the ribs on one side are overlapping one another and lying 
within the crest of the ilium, while the whole trunk is distorted and misshapen. 
Sometimes an antero-posterior curve (kyphosis) coexists with the scoliosis, 
and it is very important not to be misled by this ; still more important is it to 
remember that in cases of caries there is sometimes a lateral curvature before 
any angular curve appears : this may 
occur either in caries of the bodies or, as 
pointed out by Reeves, where there is 
disease of the articular processes or costo- 
vertebral joints. The diagnosis is to be 
made by noting the rigidity of the spine 
and usually the greater severity of the pain 
in the case of caries, as well as by the 
history of the patient. The exact position 
of such curve is by no means constant, 
and, though a curve convex to the left in 
the lumbar and convex to the right in the 
dorsal region is the commonest condition, 
the lower curve may be dorso-lumbar or 
the sides may be reversed, and so on. 
This, of course, depends largely upon the 
cause of the curvature ; thus in empyema 
the amount and position of the collapse 
will determine the curve Sometimes, es- 
pecially in rickety cases, and probably in 
those due to partial atelectasis, the curva- 
ture is local and the compensatory curves 
are so slight and diffuse as to be nearly 
imperceptible. In some cases curvature 
of the spine is to be looked upon as com- 
pensatory and advantageous, and not as 
a morbid condition ; such are slight 
curvatures which make up for inequality 

in the length of the limbs and the slighter degrees of curve due to 
empyema ; thus in one case the curve may help to hide the deformity and 
in the other assist in filling up a suppurating cavity. 

Aching pain of greater or less severity, and a general feeling of tiredness, 
with depression of spirits and tonelessness, are the principal subjective 
symptoms of lateral curvature. The pain is usually in the side and not in 
the back or chest and abdomen. 

Treatment. — Scoliosis due to congenital malformation of the spine itself 
or to deficiency of an entire limb, as well as that due to collapse of the chest- 
wall after empyema or severe atelectasis, is necessarily not entirely and in 
many cases not at all remediable, while curvature due to rickets, weakness, 

Q 




44. — Lateral Curvature of the Spine 



226 



General Diseases 



bad habits, or a shortened leg may in its early stages be entirely cured and 
in almost any stage prevented from getting worse. 

In any case the aim must be to first remove the cause tending to increase 
the deformity, to improve the general health, to strengthen the muscles and 
ligaments, and to avoid pressure and strain upon the weak parts. In the 
rickety scoliosis of young children the rickets must be treated and the child 
never allowed to remain sitting up for any length of time ; its general posture 
must be flat upon its back or face, or upon its side, with pillows so arranged 
as to straighten out the curves. The principle is not to keep the patient 
lying down, which would of course in no way strengthen the muscles, but to give 




Fig. 45. — Reclining Board for Lateral Curvature, with Extension Apparatus for the Head and 
Arms. The head straps have been omitted for clearness, and only part of the couch is shown. 
Both head and hand straps are fitted with india-rubber accumulators. 



the parts just such exercise as will make them develop, and in the intervals 
give them complete rest. 

Fresh air, friction to the spine, with frequent change of position and proper 
exercises, diet and medicine, will readily cure any case in which there are no 
fixed curves, while in the more severe cases in older children the same treat- 
ment must be adopted. In an ordinary case, the result of weak muscles and 
joints, and improper postures, the lines of management are to avoid tiring the 
muscles and ligaments, and yet to strengthen them by exercise ; to avoid the 
postures which have produced the deformity ; to counteract their effect by 
opposite positions, thus stretching contractured muscles and ligaments, &c. 
It is impossible here to enter into details of the various exercises required or 



Lateral Curvature of the Spine 227 

of the different apparatus recommended, but it may be said that in addition to 
all means of strengthening the health and improving the tone of the muscles 
— friction, salt-water douches, general exercise, and so on — a careful examina- 
tion should be made with the child stripped entirely to see what positions 
and movements tend to correct the deformity, and these should be made the 
subject of regular practice at intervals through the day. A reclining board 
such as that figured (fig. 45), or some similar one, horizontal bars, trapezes, 
dumb-bells, Sayre's suspension apparatus, and so on, are all useful as means 
of strengthening the muscles. 

Regular walking exercise for frequent short periods should be taken, the 
patient lying down afterwards, and constant watchfulness to correct any 
tendency to loll must be observed. Busch's plan of making the patient lie 
prone, with the chest and head over the end of a couch, then bending down- 
wards and raising the front half of the body against gradually increasing 
resistance, is a good method of exercising the spinal muscles. Bending 
the body forward with the knees straight and trying to touch the toes with 
the hands, then recovering and bending backwards with the head well thrown 
back ; keeping head and shoulders back and leaning towards the side of 
greatest convexity, then recovering the upright posture ; lying down with a 
large hard pillow or BarwelFs sling under the convexity of the ribs ; raising 
the arm on the concave side and pulling the body up by it by means of a 
horizontal bar or trapeze ; all these are good movements. For private 
patients much time is saved to the surgeon and expense to the patient by 
instructing a professed masseuse or gymnast to carry out such manipulations 
as the surgeon may order. 

It is a good plan to let the patient sleep in a Bar well's sling or put a hard 
pillow under the convexity of the chest and remove the one under the head, 
or substitute a thin one for it. Of forcible ' redressement ' we have no 
experience, but careful moulding of the deformity with the hands is worth 
doing. 

All spinal supports are to be reserved for cases where the deformity is 
extreme or rapidly increasing, and must be used with the greatest caution 
and never relied upon except in conjunction with the exercises and other 
means already indicated. As a means of treatment alone they are as harm- 
ful as they are wrong in principle. No cases of lateral curvature must ever 
be given up to the care of an apparatus maker. For details as to spinal 
supports, modes of measuring the deformity &c. the works of Reeves and 
others may be consulted, but, as a rule, the less supports are used the better. 

Antero-posterior Curvature. — Occasionally cases of antero-posterior 
curvature (kyphosis) are met with in children, both in infants and in those 
of older growth. These must be distinguished from the common rickety 
kyphosis. They give rise to an appearance closely resembling the stooping 
and bent-back of old age, and may be mistaken for cases of caries. Absence 
of rigidity and pain, and of evidence of rickets will usually enable these cases 
to be recognised, but it is well to watch them closely for a considerable time 
before assuming that there is certainly no caries. Exercises and a suitable 
light steel support are the best means of treatment. 

Note. — The subject of 'Flat-foot' is, for convenience sake, considered in the chapter 
on ' Club-foot.' 

Q 2 



228 Tuberculosis 



CHAPTER XIII 

TUBERCULOSIS 

Etiology. — To become tuberculous an individual must be infected by the 
Bacillus tuberculosis, and at the time of infection must present somewhere in 
his body a suitable soil for the propagation of the organism. 

There seems little doubt that anyone living under present conditions in 
a large city has plenty of chances of becoming tuberculous, and if he does 
not become so, it is not so much from lack of opportunity as from his 
tissues being incapable of playing the part of host. There is reason to 
believe that the dust of dwellings is frequently the carrier of the germs, and 
that the bacilli gain entrance into the lungs by the inspired air. There is 
strong evidence to show that the bacilli frequently find their way into the 
alimentary canal by means of milk taken as food. The infant may also 
become infected by its habit of putting all sorts of things to its mouth, to 
say nothing of the ' comfort ' which is alternately on the floor and in the 
mouth. 

The relative importance of the 'soil' as compared with the 'seed' has 
been much discussed In past times before Koch's discovery, the tubercular 
or strumous diathesis derived from inheritance was looked upon as playing 
a very important part in predisposing to tuberculosis. That it does play an 
important part is certain, as experience teaches that a vulnerability or a pre- 
disposition to become tuberculous runs in families, and indeed the same 
is true of measles, scarlet fever, and other infectious diseases. But it is 
not always easy to distinguish between the influence exerted by heredity 
and the influence exerted by bad food, exposure to cold, bad air, and by 
other conditions which lower vitality and render the individual a ready prey 
when infected. There can be no doubt that some infectious diseases, such 
as measles and whooping cough, predispose to tuberculosis by rendering 
certain groups of lymphatic glands, as the cervical and bronchial, for instance, 
a suitable soil for the propagation of the specific bacilli. 

The age of the individual appears to have an important influence. The 
foetus very rarely suffers from tuberculosis, and newly born infants rarely suffer. 
Newly born calves are apparently rarely attacked, though born of mothers 
affected with well-marked tubercular disease. Tuberculosis is not a common 
disease in infants under six months of age ; it is rare to find infants under this 
age suffering from mesenteric disease, tuberculous meningitis, or tuberculous 
disease of glands or bones. The disease is more common between the ages 
of six months and a >ear, but after a year old and onwards it becomes 



Pathology 229 

exceedingly common. With the exception perhaps of children under a year 
old, the susceptibility to tubercular disease is greater during early than 
adult life. It cannot be said with any accuracy what proportion of our child 
population suffers from tuberculosis, and statistics cannot be of much value 
on account of the difficulty of diagnosing tuberculosis of the internal organs, 
especially in the milder forms. 

Pathology. — It is safe to say that of all the organs of the body, the 
lymphatic glands, especially those which drain mucous membranes, are the 
most likely to be infected with tubercle during early life. The groups of glands 
most often affected are the cervical, bronchial, and mesenteric glands. The 
cervical group drain the mouth and pharynx, and assuming that the bacilli 
are arrested in the mouth or nose from air inspired or food taken, they may 
enter the lymphatics and become arrested in the cervical glands, and if the 
soil is favourable will develop here. Extension may take place over a wide 
area, the local glands becoming affected, and later possibly distant parts. 
In the same way if the bacilli enter the bronchial tubes they are probably 
arrested in the bronchial glands. Tuberculosis of the mesenteric glands 
arises in a similar manner, from bacilli entering the alimentary canal in 
milk or other food. In the vast majority of cases it is likely that the route 
taken by the infective germs is by the cervical, bronchial, or mesenteric 
glands. While in a large number of cases local foci are first formed in 
these glands and distant foci develop secondarily, yet this is apparently not 
always so, as it is presumably quite possible for the bacilli to find no resting 
place in the glands, but pass through them to some distant part, as for 
instance the cerebellum or the epiphysis of a long bone. In many cases the 
tuberculous process spreads by direct contact ; thus frequently the roots of 
the lungs are invaded by extension from tubercular bronchial glands which 
accompany the bronchi into the lungs. A lung is sometimes affected 
secondarily by contact with the caseating body of a dorsal vertebra. 
Tubercular peritonitis often arises from contact with caseous mesenteric 
glands or contact with tuberculous intestines. Apart from contact the 
lymphatics are doubtless the principal channels by which the bacilli are 
conveyed from one part of the body to another. It seems likely, however, 
that in some instances the micro-organisms are distributed by the blood- 
vessels. It seems probable that in a tuberculous meningitis secondary, as it 
often is, to caseous bronchial glands, the infective bacilli have travelled by 
the blood-vessels. Some authorities, however, do not believe in this method 
of dissemination. 

Besides the lymphatic glands, tuberculous disease of bone is exceedingly 
common during early life, as for instance caries of the spine, chronic hip 
disease, chronic osteo-myelitis of the small bones of the hands and toes. 
Dactylitis is very frequently associated with ' strumous nodes ' or ' cold ; 
subcutaneous abscesses. What determines the growth of tubercle in a 
particular body of a vertebra or the epiphysis of a hip ? Presumably the infec- 
tive germs have entered the system by the ordinary channels, but why is a 
particular spot selected ? It is impossible to say why that particular spot 
should be a suitable soil, but it is by no means unlikely that, in some instances 
at any rate, an injury followed by some chronic inflammation may be the 
predisposing cause. In tuberculous disease of the bones in relation to the 



230 Tuberculosis 

tympanic cavity, suppuration perhaps predisposes and the infection enters 
from the throat. 

With regard to the internal organs, there is strong evidence to show that 
the lungs are more frequently affected than any other internal organs, but at 
the same time it must be said that during early life tubercular lesions are 
much more widely distributed throughout the body than they are in adult 
life. A general tuberculosis in which lungs and abdominal organs share is 
very common. In 155 cases of tuberculosis dying in the Manchester 
Children's Hospital, it was found post mortem — 



The lungs were affected in 

„ bronchial glands were affected in 

„ mesenteric glands ,, 

„ liver 

„ spleen „ 

„ intestines „ 

,, brain „ 

,, peritoneum ,, 

„ kidney 



141 or 91 per cent 

122 or 78 „ 

101 or 65 „ 

98 or 63 „ 

86 or 55 „ 

85 or 55 „ 

72 or 46 „ 

69 or 44 „ 

65 or 40 ,, 



A careful examination of these cases was made with a view to try to 
come to a conclusion as to the route by which the infection had entered the 
system. We came to the conclusion that in at least 50 per cent, of the cases 
the bronchial glands or lungs were first affected ; that in 12 or 13 per cent, 
the abdominal organs were primarily affected, making it probable that the 
intestines and mesenteric glands had been affected by food or milk contain- 
ing tubercle bacilli. In the remainder of the cases the lesions were so 
abundant and widespread, that it was impossible to say which were the 
earliest foci. In some cases the cervical glands were caseous or cretaceous. 
We must bear in mind that the figures just given only refer to cases of 
tuberculosis dying of meningitis or from exhaustion the outcome of hectic 
fever, malnutrition or diarrhoea. They are no certain guide to the numerically 
much larger number of cases of local tuberculosis which do not die but in 
whom the tubercular process gradually comes to an end. A large proportion 
of children suffering from tubercular peritonitis recover, the lesions probably 
never being widespread. In a large proportion of children with caseous 
glands in the neck, or bone tuberculosis, the lesions remain local and 
recovery takes place. The figures, however, certainly point to the frequency 
with which the infection enters the system by the inspired air. If the bacilli 
enter the bronchi, they are arrested in a cul-de-sac and are under favourable 
conditions for entering the lymphatics, while if they enter the alimentary 
canal they are likely to be passed along with the liquid contents of the 
intestines. There is, however, strong evidence that infection does take 
place from the intestines, as in some of our cases the lesions were confined 
entirely to the abdominal organs. Inasmuch as a considerable proportion of 
cases of tubercular peritonitis recover, it is possible that the 12 to 13 per 
cent, given above as the proportion of cases infected through the ali- 
mentary canal does not by any means adequately represent the proportion 
so infected. 

One point is worthy of remark, and that is with regard to the different 



Pathology 23 1 

degrees of malignancy exhibited by tuberculous processes. Compare for 
instance an acute miliary tuberculosis running a course of a few weeks, and 
a tuberculosis of a cervical gland or patch of lupus which shows but little- 
tendency to spread or at least spreads very slowly. There is an immense 
difference between the rate of progress in some cases of phthisis and others. 
It is clear, inasmuch as the tubercular process is spread by contact, that the 
location of the lesion is important in regard to prognosis. Thus a bronchial 
gland surrounded by lung is a far greater danger to the individual than a 
caseous cervical gland. It is perhaps difficult to say how far a rapid or a 
slow process is dependent upon the bacilli themselves, whether they are of a 
malignant or mild type, or whether it is a question of soil alone. In the old 
days the mild type or slowly progressing process in which caseation slowly 
took place was not recognised as tubercular, but was designated strumous ; 
while the more acute type represented by the i grey granulation ' was 
essentially a tuberculosis. To become strumous was not a very serious 
affair ; to become tuberculous meant a death certificate at no - distant date. 
To-day we recognise that strumous processes are slowly progressing tuber- 
culous processes, and as such are in danger of involving important organs ; 
while, on the other hand, we know that tuberculosis of the lungs and 
abdominal organs may at almost any stage become arrested, and that a large 
number of cases of local tuberculosis end by complete recovery. 

Practically there is nothing to be gained by the use of the word struma 
or scrofula, nor of the several ' types ' associated with strumous disease. 
While tuberculous disease may make its appearance in the unhealthy, or in 
those in whom there is a family history of tubercle, yet it constantly crops 
up in those who are apparently in perfect health, and in children where there 
is no history whatever of any family tuberculous disease. 

It is unnecessary for us to say anything respecting the bacillus of 
tubercle, its appearances, or methods of cultivation, or to describe the histo- 
logical appearances presented by tubercular lesions. We will, however, give 
a short summary of the differences which distinguish tuberculosis in child- 
hood from that of adult life. 

1. Frequency with which the lymphatic glands are affected in children. 

2. Frequency of tuberculous lesions of bone and subcutaneous tuberculous 
abscesses. 

3. The frequency with which the abdominal organs, peritoneum, intestines, 
and mesenteric glands are affected. 

4. The frequency with which tuberculous meningitis and caseous lesions 
of the brain occur. 

5. The frequency with which tuberculosis of the lungs begins at the roots 
by infection from the bronchial and pulmonary glands. 

The student who attends the in-patient and out-patient departments of a 
children's hospital, and whose opportunities have been hitherto the study of 
tuberculosis as it affects adults rather than children, will be struck with 
some of the differences as just summarised. The form of tuberculosis of 
adults which is most common is a tuberculous disease of the lungs, proceed- 
ing from apex to base. Among children he will see a large number suffering 
from tubercular cervical glands, spinal disease, hip disease, dactylitis, sub- 
cutaneous tubercular abscesses. He will probably note more cases com- 



232 Tuberculosis 

mencingwith abdominal tuberculosis than pulmonary tuberculosis, and he will 
frequently come across tuberculous meningitis and tuberculous tumours of 
the brain. He cannot fail to note also the large number of children who 
completely recover from tuberculous disease. 

For the most part tuberculous disease will be found described in the 
chapter devoted to the diseases of various organs ; we will describe here acute 
and chronic general tuberculosis. 



Acute miliary Tuberculosis 

Acute miliary tuberculosis is perhaps commoner in early life than it is in 
after years ; it occurs at all ages during childhood, though it is rare before 
the end of the second year. Like tuberculous meningitis, with which it is 
often associated, it usually supervenes in children already tubercular, and 
occurs but rarely in children who up to the time of falling ill had been in 
robust health. There is usually a history of more or less ill health for some 
time previous to the attack ; there is a history perhaps of whooping cough 
or measles some months before, which has left the child weak, and from 
which it has never really recovered. Sometimes the symptoms of a tuber- 
culosis of the lungs or abdomen are unmistakably present, and then acuter 
symptoms supervene which mark the onset of the miliary form of the 
disease. 

Acute miliary tuberculosis occurs usually in two forms : the ' typhoid 
form,' so called because it is apt to simulate enteric fever, and the broncho- 
pneumonic form, in which the symptoms present are those of acute pneu- 
monia, the latter being set up by the presence of miliary tubercle. 

Symptoms. — In the typhoid form the commencement is usually insidious, 
and is usually preceded by a period of ill health, during which time the child 
has been noticed to waste, to be feverish at night, to cough, and not infre- 
quently to suffer from diarrhoea or pass slimy, unhealthy-looking stools. The 
child is languid, irritable ; its appetite is very uncertain, and it cares but little 
for its toys. Often there are decided signs of intestinal catarrh ; the appe- 
tite is completely lost, the tongue is coated, and the abdomen distended. An 
examination of the chest may give no decided result, or only some rhonchi 
may be heard, and there may be no very decided cough. In this stage if the 
symptoms are acute, the resemblance to an irregular attack of enteric fever 
is very close, especially if rose spots resembling those of typhoid are present, 
as is sometimes the case. The diagnosis is especially difficult in young 
children of three or four years of age, who are perhaps very irritable and 
resist any examination of the chest or abdomen, the difficulty being to dis- 
tinguish acute miliary tuberculosis from enteric or subacute intestinal catarrh 
with some patches of broncho-pneumonia. A careful and continuous record 
of the temperature is important ; the temperature should be taken morning, 
afternoon, and evening ; the variations are usually considerable, sometimes 
varying from 99 to 104 F., the highest being usually at 4 or 5 P.M. Too 
much stress, however, must not be laid on an intermittent temperature with 
considerable flights, as in some children a patch of broncho-pneumonia 
without marked physical signs will be accompanied by a striking intermittent 
temperature, and, moreover, we have seen a case of miliary tuberculosis 



Miliary Tuberculosis 233 

when the temperature only reached 101 -5° or 102 in the afternoon or evening. 
Enlargement and tenderness of the spleen may be present in an early stage ; 
in some cases there is a marked feeling of hardness about it. In one of our 
cases rigors, with enlargement of the spleen and an intermittent temperature, 
suggested malaria, but the case turned out to be acute tuberculosis. 

Sooner or later, mostly in the course of a week or two, more characteristic 
symptoms declare themselves. There is a dry hacking cough, especially 
troublesome at night ; some crepitation or loose rales are heard at the 
apices, roots, or bases of the lungs, and not infrequently a sub-tympanitic or 
high-pitched note may be elicited on percussion, or perhaps there may be 
signs of fluid at one or both bases, with a pleuritic rub. In some cases there 
is marked dyspnoea, out of proportion to the pulse-rate and fever ; it is 
caused by the presence ot miliary tubercles scattered through the lungs, with 
perhaps some disseminated emphysema or broncho-pneumonia. The hectic 
continues, and probably sooner 
or later, in the majority of 
cases, cerebral symptoms, due 
to meningitis or the softening of 
the brain which accompanies it, 
supervene. 

One of the most important 
physical signs which may be 
present is that of miliary tu- 
bercles in the choroid : the dis- 
covery of these may not infre- 
quently clear up the diagnosis 
of a doubtful case. Unfortunately 
the restlessness and irritability 
of children suffering from tuber- 
culosis often render it impossible 
to make a thorough ophthalmo- 
scopic examination. The tuber- 
cles appear as small, rounded, 
yellowish bodies, scattered about the fundus ; one or more may be seen near 
the disc, but usually they are eccentrically seated : five or six may often be 
counted. Often a branch of a retinal artery or a vein may be seen to cross 
in front of one. They appear very rapidly, being apparently formed in 
the course of a few days ; if there is tubercular meningitis, the disc may be 
swollen and indistinct. 

In a case recorded by Proebsting the detection of tubercular bacilli in the 
urine decided the diagnosis of a doubtful case in favour of miliary tuber- 
culosis. In this instance the miliary tuberculosis was secondary to chronic 
tuberculosis of the kidney. 

The duration of the disease varies, in some cases being short, often only 
three weeks ; in others, perhaps the majority, it is longer, the patient linger- 
ing for six or seven weeks. The supervention of tubercular meningitis or 
broncho-pneumonia quickly brings the end. 

The broncho-pneumonic form occurs most often in children from two 
to five years of age, and in the vast majority of cases is mistaken for an attack 




Fig. 64. — Miliary Tubercles of the Choroid ; slight 
optic neuritis. (From a drawing by P. H. Mules.) 



234 Tuberculosis 

of acute broncho-pneumonia. There is often a history of measles or whooping 
cough shortly before the attack, and probably there has been a period of 
ill health with wasting. The symptoms are precisely those of acute broncho- 
pneumonia ; there is fever, dyspnoea ; rales or crepitation are heard over an 
extended area of lung, with more or less impaired resonance over a corre- 
sponding area. The disease usually runs its course in about ten days to two 
weeks, death resulting from exhaustion and more or less asphyxia. The 
family history or previous health may suggest tuberculosis in any given case, 
but no definite diagnosis of tuberculous broncho-pneumonia can be made 
unless tubercles are seen in the choroid. The supervention of meningitis 
suggests tubercle, but a simple meningitis may accompany or follow broncho- 
pneumonia, especially in infants and young children. 

It must be borne in mind that acute or at least subacute general tuber- 
culosis, which is not of the miliary form, may occur disseminated through all 
the organs. A tuberculosis may run a course of six weeks to two months, 
accompanied by hectic and wasting, and the principal lesions found post- 
mortem are not miliary tubercles, though these may be present, but ragged 
cavities in the lungs, caseous bronchial and mesenteric glands, and caseous 
masses in the liver, spleen, and kidneys. In these cases the diagnosis may 
be difficult or impossible for the first few weeks, but careful examinations of 
the apices of the lungs will generally decide the question. 

Diagnosis. — Acute miliary tuberculosis may be confounded with acute 
disseminated tuberculosis, in which the tubercular growth takes the form of 
caseous nodules or other forms rather than the typical purely miliary form. 
The diagnosis is of very little importance except as regards the acuteness 
of the case, the miliary form being necessarily the most rapidly fatal. 
Both miliary tubercles and caseous infiltrations may be found in the same 
organ. Acute miliary tuberculosis may be mistaken for typhoid fever, 
subacute intestinal catarrh, acute broncho-pneumonia, acute endocarditis, and 
pyaemia, and we may add influenza when the attack is prolonged, as it some- 
times is for many weeks. 

In making a diagnosis the family and personal history is of great im- 
portance ; if other children or older members of the family have died of 
tuberculous disease, the probabilities in a doubtful case will naturally be in 
favour of tubercle ; but it must not be forgotten that apparently healthy 
children with a good family history will sometimes die of acute tuberculosis. 
A history of a recent attack of measles or whooping cough would be sug- 
gestive, but children with such a history may of course have typhoid or 
any other acute attack. There cannot be much difficulty in distinguishing a 
typical attack of typhoid fever from one of acute tuberculosis, but it may be 
quite impossible to make a diagnosis between an irregular and an erratic 
attack of typhoid and tuberculosis. In both diseases there may be some 
looseness of the bowels, abdominal distension, and intermittent fever : in 
both the spleen may be enlarged. It is only by having the patient under ob- 
servation for some days, and frequently examining the chest, that a dia- 
gnosis can be made. A short hacking cough, hectic fever, great variations 
of temperature, dyspnoea out of proportion to the temperature, and crepita- 
tion heard in the chest, would favour the diagnosis of acute tuberculosis. 
Any cerebral symptoms, such as convulsions, squinting, drowsiness, mus- 



Miliary Tuberculosis 235 

cular rigidity, or paresis suggesting meningitis, also favour the diagnosis of 
this disease. 

Some cases of broncho-pneumonia, where the distribution is patchy and 
the temperature markedly intermittent, closely simulate acute tuberculosis, 
and for a few days or a week a certain diagnosis cannot be arrived at. It 
is only perhaps when the pneumonia clears up, and the temperature tends 
to normal, that the suspicions of tuberculosis are relieved. 

In acute endocarditis the temperature is apt to be hectic, and in the 
absence of a bruit the diagnosis may be difficult. The presence of a bruit 
would necessarily prove the case to be almost certainly acute endocarditis, 
in spite of it resembling tubercle in other ways. 

Prognosis. — If the diagnosis of acute miliary tuberculosis can be definitely 
made, the prognosis cannot be otherwise than exceedingly grave. There 
can be little doubt that in a few cases, in an early stage, before the miliary 
tubercles are widely extended, recovery may ensue ; but when the tubercu- 
losis has become general very little hope indeed can be entertained. 

Morbid A Jiatomy. — The amount of emaciation present depends upon the 
chronicity of the case ; we have seen at the post-mortem cases in which there 
was a fair amount of subcutaneous fat in those who had died of acute miliary 
tuberculosis. On opening the chest, the lungs are found to be in a condition 
of deep inspiration, almost as if they had been injected with some fluid from 
the trachea, while miliary tubercles are seen on the surface or beneath the 
pleura. On section the lungs are found stuffed with miliary tubercles, of a 
grey colour and the size of millet seeds, usually so crowded that not a cubic 
inch in the whole lungs will be found free. They are mostly more crowded 
at the apex than at the base. Caseating or suppurating bronchial glands 
are almost certainly present. Frequently miliary tubercles are present in 
the glands. Miliary tubercles will be found crowded together in the liver, 
spleen, kidneys, and serous membranes — frequently also in the choroid, 
and on the vessels at the base of the brain. 

In other less acute cases caseous masses and peribronchial tubercles may 
be found in the lungs, and may be associated with more or less miliary tuber- 
culosis. It is curious to note that many observers have failed to find the 
tubercular bacilli in miliary tubercles, and others have found granular masses 
suggestive of spores (Biedert, Ribbert, Malassez, and Vignal). 

Treatment. — If the diagnosis of acute miliary tuberculosis can be made 
with certainty, little can be hoped for from the administration of drugs. The 
treatment must in such cases be a treatment of symptoms. If the tempera- 
ture takes high excursions towards evening, quinine, antipyrin, or phenacetin 
may be given to anticipate the rise, and the patient packed or sponged with 
cold water to reduce it. The troublesome cough may be relieved by codeia 
jelly or minute doses of opium. The strength should be maintained by a 
liberal diet of beef tea, soups, port wine, Burgundy ; extract of malt and cod 
liver oil should also be given. Iodoform sometimes appears to be useful, 
though it can hardly be said to have any power in arresting the disease ; it 
may be given in powder with sugar in half- to two-grain doses. The com- 
bination of digitalis and bark has appeared to us to produce a temporary 
improvement, but any permanent change for the better cannot be looked 
for. Creasote and guaiacol have also been used. 



236 Tu berculosis 

Scrofula and Tuberculosis 

Liability to Tuberculosis. — In certain children there is a characteristic 
tendency to inflammation from trivial causes ; this inflammation is apt to occur 
in, or rather pick out, the lymphatic tissues ; once aroused, it tends to spread, 
attacking often distant parts of the body. If its course is slow, the foci of 
disease tend to become caseous ; once started the progress seldom stops, or 
rather, though it may be arrested for a time, it is apt to be set going again 
by slight causes, even after long intervals of time. This tendency is found to 
run in families, some members showing one form of lesion, some another. 
At times different forms occur at different periods or even simultaneously 
in the same child. 

There is often, though by no means always, a characteristic appearance 
of the patient, but it is quite common to find the disease under discussion 
in children not at all answering to either description. The types usually 
described are : 1. Sanguine type — the child is tall, slight, graceful, with 
small fine limbs, clear skin, and fine silky hair ; the intelligence is bright. 
2. Phlegmatic type — the child is short and thick-set, with coarse skin and 
limbs, thick features, and a dull, flabby aspect. 3. ' Pretty strumous ' type 
— which is intermediate between the two former. 

Anatomically, in the subjects of ' acute miliary tuberculosis' we find 
always, or nearly so, somewhere in the body, caseous foci. We ought 
therefore to be on our guard against the onset of tuberculosis in vital parts 
in all cases where such caseous foci exist ; for instance, the common 
chronic osteomyelitis of the finger may be the only discoverable lesion 
in an apparently robust child, yet that child is infected with tuberculosis 
and may at any time develop other foci, and may die of visceral tubercle ; 
hence none of these diseases should be looked upon as trivial. It must, 
however, be remembered that there is much evidence to show that there 
is some antagonism between local ' scrofulous ' lesions and general vis- 
ceral tuberculosis, or rather that so long as the local lesion is unrepaired 
the internal organs escape, while recovery from the local disease may be 
followed by general infection. This has given rise to the view that the local 
disease acts as a sort of safety valve. It is probable that the truth is that 
so long as the local lesion remains quiescent, or, as it were, encapsuled, no 
general infection takes place, but if from any cause the tuberculous material 
gains access to the neighbouring vessels or lymphatics, a rapid dissemination 
of the tubercle is brought about. The disease often lies dormant for years 
or for a long lifetime, and the patient may never show any further sign of 
tuberculosis ; we must therefore not condemn all these children as hope- 
lessly tuberculous. Indeed the tendency to develop tubercular foci often 
dies out after a time, and the child becomes quite sound. Such children 
should be taken care of more watchfully than others need be, and no source 
of irritation, however slight, be allowed to continue ; carious teeth, little 
patches of herpes or eczema, slight injuries, and so on, should be seen to at 
once, lest chronic inflammation should ensue and a tubercular nidus be es- 
tablished. The diet in all such cases should be especially nourishing, and 
the usual remedies of cod liver oil as an article of food rather than a medi- 
cine, iodine in some form, iron, and, above all, sea air, should be provided 



Scrofula and Tuberculosis — Tubercular Adenitis 237 

where practicable. In the richer class of patients such children should go 
to school by the seaside. 

Details of management of individual lesions will be found in the various 
special chapters. 

Tubercular Adenitis.- — As already pointed out, the lymphatic tissues 
are those most commonly and most extensively attacked by tuberculosis, 1 
and lymphadenitis is commoner than lymphangitis, since any solid material 
taken into the lymphatic vessels is apt to be arrested in the adjacent gland. 
The thick lips and nose and the red patches and eczematous eruptions of 
children are, as pointed out by Curnow, ' reticular lymphangitis.' Under 
certain circumstances chilblains are probably a similar condition. Irritating 
matters passing up the lymph stream are not, however, by any means always 
arrested at the nearest glands, partly because the course of the lymphatics 
varies and the most commonly affected glands may be avoided by a bye- 
route and those further on attacked, and partly because the material pro- 
bably may sometimes pass through one gland and involve the next, or after 
one gland has become inflamed it may become a source of infection to the 
next in the chain. Hence search should be made for sources of irritation 
out of the usual path if none are found in the common positions. If one 
obvious enlarged gland exists the presence of others should always be sus- 
pected. The first thing, then, when a child is brought with an enlarged 
lymphatic gland, is to examine the whole area draining to that gland for 
some source of irritation, past or present : this will be facilitated by the 
following table, where the principal lymphatic glands and their collecting 
areas are given.' 2 



Table showing the Distribution of the Lymphatic Glands 
and their Drainage Areas. 3 

Head and Neck. 

Glands. Drainage Area. 

' t drain posterior half of head. 



Suboccipital . 

Mastoid 

Parotid drain anterior half of head, orbits, nose, 

upper jaw, upper part of pharynx. 
Submaxillary . . . drain the lower gums, lower part of face, 

and front of mouth and tongue. 
Suprahyoid or submental . drain anterior part of tongue, chin, and 

lower lip. 
Superficial cervical . . drain external ear, side of head, and neck 

(lying beneath platysma) and face. 

Retro-pharyngeal . . . drain nasal fossae and pharynx (upper 

part). 

1 Greig Smith has remarked upon the frequency of lesions of ' red marrow ' as an illus- 
tration of its lymphatic affinities. 

2 Curnow, Lancet, 1879. Sappey, Anat.-Phys. Path, des Vaisseaux Lymphatiques, 
Paris, 1874. 

3 Mainly from Curnow and Treves. 



238 



Tuberculosis 



Head and Neck. 



Glands. 

Deep cervical : 

Upper set along carotid 
sheath : 



Drain A( i 



Lower set in supra- 
clavicular fossae : 



Supracondyloid l 
Axillary 



drain mouth, tonsils, palate, lower part of 
pharynx, larynx, posterior part of tongue, 
nasal fossae, parotid and submaxillary 
glands, interior of skull, and deep parts 
of head and neck. 

drain upper set of lymph glands, lower 
part of neck, and join axillary and 
mediastinal glands. 

Upper Extremity. 

. drain three inner fingers. 

. drain upper extremity, dorsal and scapular 

regions, front and sides of trunk and 

breast. 

Lower Extremity. 

Anterior tibial and popliteal : drain the deep lymphatics of the leg, and 

receive some vessels from the skin of the 
leg and foot, chiefly the outer side. 
Inguinal : 

Femoral set (superficial) . drain superficial vessels of lower limb and 

partly of buttock and genitals, also 
perinaeum. 
Horizontal set (superficial) : drain abdomen below umbilicus, buttock 

and genitals. 

The deep vessels of the lower limb 
go to the deep glands along the femoral 
vein. 



Iliac 
Lumbar . 
Sacral 



Abdomen. 

drain the pelvic viscera and the deep vessels 
of the genitals partly. 

drain all the lower glands, uterus, testes, 
ovaries kidneys. 

drain the rectum. 

Roughly, the umbilicus is the water- 
shed draining to the axilla and groin, 
but the vessels cross and overlap both 
vertically and horizontally. 



Perhaps the most commonly enlarged glands are those of the neck and 
submaxillary regions, parts obviously much exposed to irritation ; thus eczema 
of the scalp, the irritation of pediculi, &c. give rise to enlargement of the 
occipital and upper cervical glands ; herpes about the nose to irritation of the 



Occasionally there are glands in the bend of the elbow. 



Tubercular Adenitis 239 

parotid or submental glands ; while carious teeth, ulceration of the gums, and 
so on, affect the submaxillary and cervical groups. The upper set of cervical 
glands are found enlarged from irritation of the meatus externus in cases of 
otorrhcea and in cases of tonsillitis. As already mentioned, a lymph gland 
overlies the tonsil, and is usually enlarged in affections of that structure, 
which is not perceptible from the neck under ordinary circumstances. Treves 
points out that those glands which drain areas rich in lymphoid tissue 
are the ones most commonly enlarged ; hence the cervical, bronchial, and 
mesenteric groups are those most often affected. 

The enlargement of lymphatic glands is sometimes acute at first, and they 
are then tender and painful ; in other instances the swelling is chronic and 
painless from the beginning. The glands form hard, rounded, or oval masses 
freely movable in the deeper tissues and beneath the skin, unless there has 
been cellulitis around the gland (periglandular inflammation). In chronic 
cases the overlying skin is natural, and usually several glands can be felt ; 
often a chain of them, varying in size from a pea to a walnut, can be traced. A 
mere transitory irritation may start inflammation in a gland, and then, 
though the local source has entirely disappeared, the enlargement may persist 
and other glands in the chain be affected, as already described ; hence we 
must not conclude that there has been no primary source of irritation, and 
that the glandular affection is spontaneous because we can find no cause for 
the enlargement. Cold, or some trifling injury, a sore upon the skin or 
mucous surface, soon healed and forgotten, or perhaps never noticed, is suffi- 
cient to set up chronic tubercular adenitis, which may spread and last for 
months or years. Primary adenitis not due to absorption is probably very 
rare. Treves points out that cervical adenitis may be caused by extension 
from within the chest or other distant parts. 

After a time, unless the process subsides, the glands become very hard, 
and by their size and number give rise to great disfigurement and occasion- 
ally to more serious trouble. Goode, of Cincinnati, has recorded a case of 
death in a baby five months old from pressure of a caseous gland upon the 
carotid sheath. These swellings are seldom painful ; after a time one or more 
patches of softening may appear, and as the process goes on the skin becomes 
red or livid, and finally thinned and perforated ; thin watery, sero-purulent 
fluid with flakes of lymph and cheesy matter then escape, more rarely 
fairly healthy-looking pus ; occasionally the discharge is clear glairy fluid, 
like the contents of some mucous cysts, but in such cases there is almost 
always some more purulent matter at the bottom of the cavity, which can 
be squeezed out. The discharge may go on indefinitely, and an ulcer is 
formed which has little tendency to heal, and is bounded by thin, livid, 
undermined, unhealthy edges. If healing does take place the scar is 
puckered and unsightly, often with bridges or tags of thin insensitive skin 
hanging from it, and little black spots due to accumulation of dirt and 
secretion in the hollows of the scar. Such is the condition seen in an old 
1 scrofulous neck.' 

If such a gland as that above mentioned is examined in the early stages 
of the process, it will be found firmer and paler than in health, but not other- 
wise obviously altered ; a little later patches of yellow cheesy material of 
various sizes will be found scattered through the gland, sometimes in one or 



240 Tubei'culosis 

two large foci, at other times in numerous small ones ; the capsule of the 
gland is thickened. Later still, these caseous foci break down, the greater 
part of the gland tissue is destroyed, and the gland itself becomes converted 
into a bag of cheesy or flaky pus and detritus, with walls composed of the 
capsule and more or less of the gland tissue remaining unsoftened. It 
happens, however, sometimes that, instead of the gland breaking down and 
softening in the centre, suppuration takes place in the cellular tissue round 
it— periglandular abscess ; this burrows round the gland and isolates it, so 
that there is a solid mass of gland tissue lying in an abscess cavity, and per- 
haps attached to the surrounding tissues only by the structures passing to its 
hilus. In this last case, when the skin gives way, instead of a deep ulcer 
there is seen a round pinkish or yellowish-white mass projecting from the 
middle of a circular sore, the edges of which are loose, undermined, thin, and 
livid ; there is often but little discharge, and no tendency to heal, or, indeed, 
to alter much one way or the other. Where many glands are enlarged, all 
stages, from the first primary enlargement to the last-named condition, may 
be seen at once, and sometimes the whole neck from ear to ear is marked by 
ulcers, scars, and enlarged glands in various stages. In such cases it will 
usually be found that many teeth in one or both jaws are carious, and acting 
as sources of irritation. 

It must, of course, be remembered that all such glands do not go on to 
suppuration, and perhaps in children there is more chance of resolution 
than in adults ; however, the majority do suppurate if they remain enlarged 
for more than a short time. 

Coexisting with the glandular abscesses and sores will often be found 
superficial ulcers, round or irregular in form, often scabbed over, and only 
discharging at times. The edges of the sores are usually unhealthy and 
undermined, and their bases glazed or covered with coarse, unhealthy granu- 
lations and caseous detritus ; some of the ulcers are no doubt caused by the 
discharge of broken-down glands ; in these a small aperture will be found 
leading down to the underlying gland ; others are probably due to abscesses 
beginning in lymphatic vessels, due to tubercular lymphatic emboli, or rather 
thrombi — tubercular lymphangitis, 'strumous nodes ;' others again probably 
to local cutaneous tuberculosis. 

Diagnosis. — Tuberculous adenitis and ulcers may be mistaken for 
syphilitic ulceration, which gives rise to very similar appearances, except 
that ulceration predominates over the glandular enlargement. It must be 
remembered that congenital syphilis and tuberculosis may coexist. The 
presence of other evidences of syphilis will nearly always clear up a doubt. 

Simple acute adenitis is recognised by its short history and by the pain 
and great tenderness of the part, as well as by the presence of an acute 
source of irritation, such as an alveolar abscess or acute tonsillitis, and by 
the fact that usually only one gland is enlarged, though several may be 
tender. 

Simple ?ion-tubercular chronic adenitis may occur as the result of acute 
inflammation, but this usually rapidly subsides under treatment and affects 
but one gland ; if the affection is obstinate, suspicion of its tuberculous 
nature should be aroused. 

Lupous ulcers are the only other condition likely to be mistaken, and as 



Treatment of Tubercular Adenitis 241 

these are also tuberculous, the mistake is of little importance. The presence 
of well-defined lupous tubercles is the distinguishing feature. 

Tuberculous abscess of the skin, ' scrofuloderma,' ' scrofulous gumma,' 
and ' strumous node,' are the names applied to small tuberculous foci pro- 
bably in the lymphatics which, at first hard and solid, usually break down, 
though sometimes they are absorbed. These little swellings are often 
found in the thickness of the skin itself about the limbs, face, or trunk. 
Occasionally the mischief spreads, and a large cold abscess or tuberculous 
ulcer may result. 

Chronic tonsillar hypertrophy is considered by Treves to be 'almost 
pathognomonic of scrofula ; ' though very common in tubercular children, we 
think it is often met with in those who show no other signs of tuberculosis ; 
it may occur during the first few months of life. Infantile leucorrhcea and 




Fig. 46a. — Tubercular Ulceration of the Skin of the Foot, showing imperfectly formed scar-tissue 
overlying the tuberculous granulations. A form of so-called Lupus hypertrophicus. 

certain vulvar ulcers have been supposed to be tuberculous ; no doubt many 
cases of aural suppuration are so. 

Treatment. — The treatment of tuberculous adenitis consists at first in 
carefully removing all sources of irritation ; carious teeth, enlarged tonsils, 
patches of eczema, nasal catarrh, otorrhcea, chafed heels, and so on, should 
all receive attention according to the seat of the enlarged glands and 
the source of the trouble. Next, the general measures of diet and health 
already mentioned must be carried out. As to the local treatment of the 
glands themselves, this must be managed according to the stages of the 
disease. (1) In the early stage, before caseous foci have appeared, after 
removal of the source of irritation, the glands should be left quite alone, in the 
hope of their subsiding. If no improvement takes place in a fortnight, the 
glands should have a piece of unguentum hydrargyri oleati, of the size of a 
small pea, gently rubbed over them night and morning. Painting with 
tincture of iodine we do not approve of ; it is far more likely to increase the 

R 



242 Tuberculosis 

irritation of the glands than to lessen it. Should the enlargement not yield 
to these means, and should the stage of caseation, known by a duration of 
two or three months with considerable enlargement and much hardening of 
the glands, be reached, the best treatment is to cut down upon and shell out 
the glands entire — a very easy operation at this stage where only one or two 
glands are involved, a much more difficult and sometimes impossible one 
where many glands in a chain are enlarged and there is periglandular in- 
flammation. In favourable cases an incision through the skin and fascia, 
and then through the sheath of the gland, followed by pressure at each side 
with the fingers, will render enucleation of the mass quite easy. All the 
glands felt to be enlarged should be removed, all bleeding stopped, and the 
edges carefully brought together, no drainage being used if the wound is 
clean. The resulting scar is slight, and much less unsightly than that left 
in cases where suppuration has gone on. The plan of puncture with the 
thermo-cautery we have not found satisfactory ; it is apt to leave intractable 
sinuses. 

In the next stage, when the gland has softened down, if there has been 
no periglandular mischief, it may be still possible to dissect the mass out, 
and, if so, this is the quickest and best method ; it is, however, impracticable 
if the glands have become matted to the surrounding tissues : in such cases 
the abscess should be opened by an incision about half an inch in length ; a 
long incision is not necessary, but it must be sufficient for free manipula- 
tion and drainage. After opening the abscess a Volkmann's spoon is passed 
in, and all the gland tissue carefully and thoroughly scraped away : if any is 
left the wound will not heal, but the part remaining will caseate, break down, 
and keep open a sinus ; hence, if all the gland cannot be scraped away, the 
most satisfactory plan is to enlarge the incision and dissect out the remaining 
parts. Injection of chronic glandular abscesses with a solution of iodoform 
in ether is worth a trial where operation is not allowed ; we have seen 
them completely disappear under this treatment. Where, as often happens, 
two or more glands near, but not fused with, one another have broken down, 
the further ones may often be reached, as pointed out by Mr. Teale, by 
thrusting the spoon through the adjacent walls and thus emptying all the 
cavities through one opening. The wound should be well dusted with iodo- 
form and drainage provided for. When the abscess has already burst and 
left a sinus, the same treatment should be adopted. Where ulcers have 
formed with undermined edges these should be scraped or clipped away 
flush with the healthy skin : a large wound may thus be sometimes left 
where there was but a small opening before, but the ultimate result will be a 
much less unsightly scar, as well as more rapid healing, if this devitalised 
skin is removed ; all the unsightly tags and bridges will thus be avoided. 
Where there is a protruding isolated gland in the middle of a sore, if it is 
soft it may be scraped away. We cannot too strongly urge that on every 
ground it is far wiser to remove glands by clean excision as soon as they have 
become chronically enlarged, and before there is any breaking down or in- 
flammation round the gland. 

Mr. Teale has pointed out that where one superficial gland is enlarged 
and suppurating there is usually another, lying beneath the deeper fascia, and 
that, unless this is cleared out, the source of discharge is not removed and 



Treatment of Tubercular Adenitis 243 

the sinus will not heal. It is necessary to look carefully sometimes to find 
the channel leading to the deep gland, but it is there and must be followed by 
the spoon, and the second mass removed. Mr. Teale uses a special dilator 
to stretch the sinus, but a dressing or sinus forceps will usually be found to 
answer all purposes. 

Iodoform is the best dressing to apply to these sores at first, and later on 
they do very well with iodide of lead ointment. 

Where several sinuses are left in the neck it is a good plan to use, as 
advised by Treves, a gutta-percha or leather stock to keep the parts at rest 
(the sawdust collar will be found useful for this purpose), and in other parts 
of the body efficient pressure by pads and bandages or by a truss is often 
useful. 

Where depressed scars remain after gland diseases Adams's or Reeves's 
operations maybe employed. The former loosens the skin by subcutaneous 
division of the scar, and by daily manipulation keeps it from becoming 
reattached till the hollow is filled up. Reeves props up the depressed skin 
upon a wire passed beneath it, which may be left in permanently, or removed 
if it sets up irritation. We have had a good result from the latter method. 
A far better plan, however, in most cases is to cleanly excise the whole 
scar, and bring the edges of sound skin accurately together by means of 
sutures ; thus a linear cicatrix takes the place of the irregular puckered or 
depressed scar. 

Where the popliteal or inguinal glands are involved the limb should be 
kept extended and fixed to a splint. Suppurating popliteal glands are apt 
to give rise to serious trouble ; the matter tends to burrow far up the limb. 
In one case we had to amputate the thigh where an abscess, beginning 
in the popliteal lymphatics as the result of an irritated chilblain, eroded 
the popliteal artery, opened into the knee joint, and burrowed up to the 
pelvis. 

Acute adenitis, if seen before suppuration has occurred, will usually sub- 
side if the source of irritation is removed and the part well fomented after 
smearing it with extract of belladonna. If pus forms it should be let out as 
soon as possible. 

General Surgical Tuberculosis 

A condition perhaps best described as ' general surgical tuberculosis ? 
is common, the term being applied to those cases where there are tubercu- 
lous foci scattered far and wide over the body in various tissues. Thus 
children are seen with ulcers of the hands, abscesses or still unsoftened 
nodes along the course of the lymphatics of the fore-arm, and a supra- 
condylar gland enlarged : perhaps a patch of ulceration on the cheek 
and submaxillary adenitis, phlyctenular ophthalmia, tubercular osteo- 
myelitis of one tibia, with disease of the tarsus on the opposite side, and 
so on. Such a combination is by no means a rarity : not very long ago we 
had in the hospital a boy with disease of one hip, one elbow, one ankle, 
and sacro-iliac disease ; in another the shoulder, ankle, and wrist were 
all excised for tuberculous disease. Such cases, if they are neglected, 
gradually lose strength and sink, but good food and sea air, combined 

R 2 



244 Tuberculosis 

with removal of the disease as soon as it is evident that spontaneous repair 
is impossible, will often work wonders. 

Operation should be deferred till it is seen what nature can do ; but if 
with the improvement in the child's health no progress is made locally, or if 
there is pain or much discharge, the affected tissues — bones, joints, &c. — 
should be removed. We have often been surprised at the rapid and com- 
plete repair effected in such children, and even in the cases looking most 
desperate locally, resections or scrapings will sometimes succeed and am- 
putations prove unnecessary. 1 But in all these children relapses will occur 
if the health is again allowed to fail from bad food and hygiene. 

As regards details of local treatment in such cases, we find iodoform 
mixed with an equal quantity of boric acid and dusted on, or iodoform 
ointment, the best application. Where operation is called for, all dead and 
carious bone should be excised or scraped and gouged away, all soft caseous 
and pulpy granulation tissue removed, and undermined livid edges of skin 
clipped off. The incisions may sometimes be closed with sutures and 
primary union obtained ; where possible this should be attempted. If, 
however, the destruction of the skin renders union impossible, the wounds 
should be left freely open ; they often heal with great rapidity and leave but 
little deformity. Amputation is sometimes required for tarsal and knee joint 
disease, but in the upper extremity we have never seen a case that required 
it, except in the fingers, though some have at first appeared hopeless enough. 
Caries of the spine in such children is the most serious condition, from its 
inaccessible position ; but even this is not hopeless. It is not so common as 
might be expected to find visceral tubercle in these patients, and this is 
probably one of the reasons why they have been called scrofulous and not 
classed as tubercular. The term ' surgical tuberculosis ' has been used to 
imply that operative treatment can do much for them, and that the lesions 
are external. The following case illustrates this. 

Surgical Tuberculosis. — Edward C, aged 9 years 6 months. Admitted November 7, 
1885. No tubercular history. Always healthy till two years ago, when an abscess 
appeared at the back of the leg, and others subsequently elsewhere ; they have continued 
to discharge since. Four months ago he fell upon the elbow, and an abscess formed, 
which was opened, and has been discharging since; joint stiff. On admission, a sinus 
over the outer end of the left clavicle, leading to bare bone. Abscesses and enlarged glands 
in the neck ; a sinus on the left buttock and another over the inner condyle of the left 
humerus. 26th, several small loose sequestra removed from the cavity in the clavicle, close 
to and involving the acromio-clavicular joint ; abscess in neck scraped out and a deep 
gland beneath the fascia scooped away ; some caseous bone scraped from inner condyle 
of humerus. 27th, much pain in elbow, which subsided partially by the 29th ; he did fairly 
well, and was sent out on December n with all the ulcers &c. doing well, except the 
elbow, which remained swollen and tender. Such cases are very frequently met with. 

Non-tubercular Abscess 

Chronic Abscess. — Chronic abscesses, whether tubercular or not, may 
now be dealt with much more speedily and satisfactorily than in former 
times. In all cases, of course, the source of irritation should be looked for 
and if possible removed ; unless this is done success cannot be reasonably 
expected. 

1 See, however, chapter on Bone and Joint Diseases. 



Non-Tubercular Abscess 245 

In some instances, if the contents of the abscess are drawn off through 
an aspirator and an emulsion of iodoform in glycerine injected (from 5J. — 3 SS - 
being a usual quantity to use), the abscess will slowly subside. This 
method is not, however, likely to succeed where any irritating or much 
caseous material is present. In such cases the abscess should be freely 
opened and its contents and whole lining most carefully scraped and rubbed 
away ; this part of the proceeding must be done thoroughly or the operation 
will fail. 

The abscess cavity should then be well washed out with perchloride 
of mercury lotion of strength 1 to 3,000, and, after being thoroughly dried 
out, either a mixture of iodoform and boric acid in equal parts should be 
dusted in, or some of the iodoform emulsion injected. The wound is then to 
be carefully and completely sewed up, all excess of fluid being squeezed out 
just before the dressings are applied. The dressings should consist of wood- 
wool wadding or some similar substance packed carefully on over a layer of 
wet gauze. The dressing should be so applied that the walls of the cavity 
are accurately kept in contact and firm pressure made. In successful cases 
the wound need not be disturbed for ten days or a fortnight, when it will be 
found soundly healed. If, as sometimes happens, the wound heals but the 
abscess refills, either the source of irritation at a distance has not been 
removed, or the cleaning out of the cavity has not been complete ; the 
operation should be repeated, and will probably be successful. In cleaning 
out the cavity it is useful to twist an artificial sponge tightly into all parts 
of the cavity and screw it round so as to entangle and wipe out all caseous 
material. 

Deep Cervical Cellulitis — Angina Ludovici — is a very serious affection ; 
the mischief apparently begins as a periglandular inflammation, goes on to 
sloughing, and may perforate the cheek. There is at first a brawny infiltration 
of the submaxillary region ; the skin in milder cases is pale and marked by 
turgid veins ; in the more severe and acute cases, however, a deep brownish- 
red discoloration appears. The whole neck may be involved, and there is 
great swelling, with marked prostration, and sometimes dyspnoea or dysphagia 
from mechanical pressure. The disease is met with usually in children under 
three years of age, often in infants, and occurs under similar conditions to 
cancrum oris. Early and free incision is urgently required ; usually much 
foul brown serum or sero-pus escapes. Free stimulation and abundant 
nourishment are required, with removal from insanitary surroundings. 
The mortality of these cases, which much resemble those of scarlatinal 



Case. — Female, age 1 year 9 months ; neck swollen a fortnight ago ; on admission, 
right side of neck tense, hard, brownish-red ; swelling reaches to clavicle ; swelling incised, 
serum only escaped ; much fever before incision ; skin sloughed freely, and pneumonia 
set in, child dying on seventh day. 

Post-morte?n. — Abscesses in lungs and sanguineous pleuritic effusion. 



246 The Specific Fevers 



CHAPTER XIV 

THE SPECIFIC FEVERS 

Feverishness. — Children more often than adults are apt to suffer from 
attacks of feverishness, the temperature rising suddenly without any obvious 
cause, remaining raised for a day or two, much to the alarm of the friends 
and the medical attendant, and returning to normal without any clue having 
been obtained as to the cause. Perhaps the feverishness is less acute, but 
continuous for some weeks, rising in the evening and falling in the morning, 
without any diagnosis being made. It is hardly needful to insist that in any 
given case no effort should be spared to find out the cause of the fever, the 
chest being stripped and carefully examined by auscultation and percussion, 
while the skin and fauces should be minutely scrutinised in a good light. 
Inquiries should be made as to what the child has taken in the way of food 
prior to the attack. If the attack is sudden, the temperature rising to 
103 or 104 or more, epidemic influenza, acute pneumonia, scarlet fever, 
or acute dyspepsia from the ingestion of unsuitable food will doubtless be 
suggested. 

In children under three years of age, a high temperature with convulsions 
is often due to acute pneumonia, and a careful examination of the lungs, 
especially at the apices, should be made ; in older children there may be no 
convulsions, but usually, if the physical signs are not distinctive, there is 
some stitch in the side felt on coughing, with more or less dyspnoea. In 
scarlet fever there is usually vomiting and often diarrhoea, and the appear- 
ances in the throat and skin soon become distinctive. During the first twelve 
or twenty-four hours it may be difficult to distinguish between scarlet fever 
and an acute gastro-intestinal infection, as sometimes the latter will produce 
severe symptoms of vomiting, diarrhoea, and fever. Or there may be no 
diarrhoea or sickness and only feverishness. The diagnosis in epidemic 
influenza has often to be made from the fact that it is prevalent in the house 
or neighbourhood rather than from the symptoms, which are so frequently 
indefinite ; a temperature of 104 or io5°with convulsions is not uncommon. 
In many cases it is wise to wait before giving a definite opinion. In infants 
and young children the cause of an unexplained high fever may prove to be 
an acute otitis which has been overlooked till pus has made its appearance 
at the external meatus ; such cases are very apt at first to be mistaken for 
meningitis (see fig. 47). 

In some feverish attacks we have noticed an enlargement of the cervical 
glands, either the deep cervical at the angle of the jaw, or the glands under the 
upper part and posterior edge of the sterno-mastoid, without any appearances 



Feverishness 



247 



of irritation in the tonsil or pharynx ; possibly there may be such a disease 
as an acute idiopathic adenitis, or some poison may perhaps be absorbed 
from the pharynx and enter the glands without setting up any local lesion at 
the point of absorption. 

Such cases have been described by E. Pfeiffer, Heubner, and Rauchfuss 
under the name of gland fever. The attack, according to Pfeiffer, is sudden 
and the fever moderately high ; there is complaint of tenderness in the neck, 
and some of the cervical glands, usually those at the posterior border of the 
sterno-mastoid, or the occipital glands, are swollen and tender. In a few 
days the temperature falls and the glands become normal. In a few instances 
the attack has been more severe and has lasted longer. In these cases no 




Fig. 47. — Temperature Chart showing high temperature due to an acute otitis in an 
infant of seven months. 



abnormal appearances have been detected in the tonsils or nasal mucous 
membrane. The glands never suppurate. Pfeiffer has noted several of 
these cases in one house at the same time, the disease being infectious or 
epidemic. 

We are, however, rather inclined to think that while ' gland fever ' does 
undoubtedly take place, it is rarely idiopathic, but the result of absorption of 
toxic materials from a mucous membrane. ' Gland fever ' often occurs in 
scarlet fever and other various forms of tonsillitis, the throat may be 
apparently well or hardly abnormal, yet the cervical glands are swollen and 
tender, and the patient feverish. 

Acute cerebral congestion or ' sunstroke ' may be accompanied by high 



248 



The Specific Fevers 



fever, quickly followed by death, though fortunately this is not always the 
case. In many cases with a high temperature and cerebral symptoms, such 
as coma, delirium, or torpor, it is often difficult to say whether there is some 
cerebral disease, or whether the high temperature and poisoned blood are 
not causing the cerebral symptoms, the brain itself being normal. When 
the temperature rises more slowly, taking several days to reach its greatest 
elevation, as is the case in measles, typhus, typhoid, and smallpox, a diagnosis 
cannot be made for a few days, till characteristic symptoms appear. The 
hard cough, suffused eyes, and rash of measles, the headache, delirium, and 
coma of typhus, the backache, and papules of smallpox, settle the diagnosis. 



iiiiiiiiiiiliii 




WBBSBSBSBBBBk 




hiiSi 



IlilllFikWiiiililliliiliiiiii 



Fig. 48. — Temperature Chart of a case of Erythema Nodosum. The girl was in hospital convalescent 
from Acute Pneumonia. The cause of the fever was unknown till a number of typical nodes made 
their appearance. 

This is sometimes the case in erythema nodosum ; there are some few days 
of fever with no definite symptoms, and then the characteristic red flattened 
nodes make their appearance (see fig. 48). 

The diagnosis as to the cause of fever is often very difficult when the 
fever assumes the intermittent or remittent type, going on for some days or 
weeks without any characteristic symptoms developing. Such cases were 
formerly designated 'low' or 'continued fever,' and while it is not wise to 
use such indefinite terms, we must be prepared to find cases of intermittent 
fever in children in which it may be quite impossible to make a diagnosis. 
A sub-acute or chronic gastro-intestinal catarrh, creeping pneumonia, a low 
form of enteric fever, a tubercular peritonitis or suppuration may be present. 



Scarlet Fever 249 

There may be, as Dr. Foxwell suggests in these cases, a condition of 
general catarrh, including both alimentary and respiratory tracts. In all 
such cases a most careful examination should be made of the chest, abdomen, 
and retina for disseminated tuberculosis, in the hope of detecting something 
which will throw light on the attack. We must not forget that some of these 
cases of protracted remittent fever are in reality cases of miliary or local 
tuberculosis in which healing eventually takes place. We feel sure we have 
seen such cases. 

Scarlet Pever 

Scarlet fever is a specific fever of a highly infectious and dangerous 
nature characterised by tonsillitis, fever, and a diffuse rash ; it occurs in 
epidemics, but is always more or less endemic in large populations. It is 
easy to understand the occurrence of epidemics in a small population where 
the fever exhausts the soil, as it were, by attacking all those susceptible to 
its influence, and then disappears for a while to prevail at a later period, 
when the infection is re-introduced and the population contains again a 
number of the unprotected. It is more difficult, however, to understand the 
cause of epidemics in large cities where the infection is always present, 
unless we assume the existence of some unknown influence which favours 
the spread of the disease at one time more than another by rendering those 
who are unprotected by a former attack more than usually susceptible to the 
infection. Thus epidemics of scarlet fever are more common and wide 
spread in the autumn than at any other period, and it would appear that at 
this 1 season either the poison is apt to be more intense, or individual 
susceptibility greater. Individual susceptibility varies greatly with age 
infants under six months of age are rarely attacked, during the second year 
the susceptibility is greater, while children during the fourth to the seventh 
years are most often attacked. The susceptibility then appears to diminish 
as age increases, though, as already remarked, varying strangely from time 
to time. Thus it may happen that a medical man or nurse may come in 
contact with scarlet fever cases for weeks or perhaps months without con- 
tracting the disease and yet finally take it. In one case which came under 
our notice a probationer nurse was engaged in nursing in a scarlet fever 
ward for six months without being attacked ; many months after, while 
nursing in a surgical ward at another hospital, she contracted a smart attack 
of scarlet fever from a sporadic case arising in the ward. In another case 
a child had a severe attack of scarlet fever twenty-nine days after admission 
to the scarlet fever ward. In this case it was supposed to have had an 
attack of scarlet fever for which it was sent in ; but second attacks of scarlet 
fever are rare ; they do, however, undoubtedly occur, as in the following case: 

Scarlet Fever ; second attack. — Thomas R. , aged 6 years. Vomited June 26, rash 
noted same day; admitted to hospital June 29. There was a well-marked rash, the 
tonsils were swollen, with patches of exudation ; there were two or three degrees of fever 
for a few days. Discharged August 20. He vomited August 21 ; admitted August 25 
with a typical attack of scarlet fever. There was a well-marked rash, tonsillitis, and 
ferer. 

Scarlet fever is apparently not so infectious as measles — a large number of 
cmidren and adults escape being attacked ; thus Biedert found in an epidemic 



250 



The Specific Fevers 



which prevailed in an isolated village (Neunhofen) where the inhabitants 
freely mixed with one another, and where no isolation of the fever patients 
was possible, that about 58 per cent, of the children unprotected by a former 
attack contracted the disease, though only about two-thirds of these had well- 
marked symptoms, the rest having sore throats only. In different epidemics 
the number attacked varies extremely. 

The mortality varies in different epidemics ; thus, in the fever ward of 
the Children's Hospital, Manchester, it has varied from 6 to 25 per cent, in 
different years ; during the years 1873-1897, the average mortality among 
3,319 cases treated was 12 per cent. During the eighteen years 1880- 1897 
(inclusive) 2,840 cases were treated with an average mortality of 9*6 per cent. 
This average mortality closely corresponds with the figures given by Collie 
of the mortality in the London, Stockwell, and Honierton fever hospitals, 
where, in upwards of 10,000 cases of scarlet fever, the mortality was 12*5 
per cent. As in all probability many of the milder cases of fever never 
come into hospital at all, 10 per cent, mortality given by W. Squire as the 
average appears to be as nearly correct as possible. Age influences the 
mortality very considerably ; the mortality is high during the first three or 
four years of life, amounting to 25 to 30 per cent. ; it continues high till the 
age of five or six years is reached, declining after this till the age of twenty- 
one, again increasing after this epoch. 



Table showing mortality in 2,840 cases of scarlet fever at differ e?it ages. 



- 


Boys 


Deaths 


Per cent. 


Girls 


Deaths 


Per cent. 


Total Deaths 


Per cent. 


Under 2 yrs. 

2-5 .- 

5-io „ 

10-14 ,, 


70 
481 
628 
174 


is 

80 

3* 

4 


21 4 
16-6 
4'9 1 

2'2 


82 
489 
686 

230 


27 
66 

1 


32-9 
134 

2-6 


152 42 
970 146 

i 1314 77 
404 10 

2840 275 


27-6 

is 

5-3 
2 "4 , 




J 353 


130 


9-6 ! 


1487 


145 


97 


9-6 i 



Are there any morbid conditions of body which predispose to scarlet 
fever ? Very little is definitely known about such conditions ; individual sus- 
ceptibility varies in the most erratic manner, or at least is governed by no 
known laws, and it cannot be said that ill-health in any way either favours 
or protects from attacks. To this, however, must be added that it is our 
experience that operation cases and surgical cases with open wounds are 
more liable to contract the disease than are healthy children. The so-called 
surgical scarlet fever is simply scarlet fever occurring in a surgical case 
(vide infra). 

The strong and healthy appear to be as frequently attacked as the 
weakly, and the attacks are often fatal to such ; it is by no means uncommon 
to see on the post-mortem table children who have succumbed to malignant 
scarlet fever looking fat and plump, and who were apparently in the best of 
health when attacked. 

The tra?isference of infectio?i from the sick to the healthy takes place in 
various ways ; it may be by direct contact, the breath or the exhalations from 
the fever patient may be inhaled, or it may be carried by means of clothes 



Scarlet Fever 251 

or wearing apparel or bedding which has been in contact with the sick. It 
is highly probable also that the excretions of the patient are infective, the 
urine, faeces, and discharges from the ear or nose. The poison of scarlet 
fever appears to retain its vitality for many months, fever breaking out again 
and again in houses which have been imperfectly disinfected. One of the 
common — but often unsuspected — sources of infection in schools and the 
general population, is the number of individuals who have had mild and 
unrecognised attacks mixing with others and so spreading the infection. 

Incubation. — Mostly two to five days, though it maybe much less, perhaps 
only a few hours ; forty-eight to seventy-two hours is a common period, but 
in many cases where slight sore throat precedes for some hours the more 
definite symptoms it is impossible to state the period of incubation with 
exactness. In the majority of cases, if the initial vomiting be taken as the 
first symptom, it will be found that the incubation is under three days. It 
cannot be said with certainty that it may not be more than five days, but 
such cases must be very exceptional. 

Pi-emonitory Symptoms.- — The invasion in the case of children is usually 
sudden, the first symptom being nearly always vomiting ; this may come on 
after a hearty meal. There may also be diarrhoea. In older children and in 
adults there is usually nausea if not vomiting, sore-throat, headache, shivering, 
and loss of appetite. ' Sore-throat ' with vomiting in a child or adult is ex- 
tremely suspicious of scarlet fever, especially if fever is present. The tem- 
perature usually runs up quickly to 103 or 104 , and perhaps the patient 
sits over the fire on account of feeling chilly ; in some cases there is slight 
delirium. An attack of vomiting and diarrhoea coming on suddenly with 
feverishness (io3°-io4° F.) is very probably the commencement of scarlet 
fever, and in such cases death may take place within twenty-four hours of 
the onset. 

Symptoms a?id Course. — Medium Forms.— The premonitory symptoms 
are usually followed within twenty-four hours by the characteristic rash. 
This is said to make its appearance first about the neck, but there is no cer- 
tainty about this, and traces may be seen of it on the backs of the hands and 
wrists, or on the thighs or abdomen, when it is present nowhere else. In 
some cases it is first visible on the back. At first the rash is faint though 
perfectly characteristic, taking two or three days to reach its height. In 
other cases it disappears in the course of twenty-four or forty-eight hours, 
having at no time been more than a fine faint rash. When typical it 
cannot be mistaken for any other rash. Viewed from a short distance, the 
whole body excepting the face is of a uniform bright red colour ; examined 
closely, it consists of a multitude of red points which correspond with thehair 
follicles ; these points are surrounded by zones of erythematous redness which, 
joining with one another, give a general diffuse red appearance to the skin. 
Sometimes the rash consists of the points only without the erythema ; in this 
case the redness is necessarily less vivid. In rough skins the rash may be 
coarsely punctiform ; that is, there is a condition of ' goose skin,' each point 
being large and the rash therefore coarse. Sudamina are not uncommon. 
In other cases the rash is patchy on the limbs, and when this is so, the case 
may simulate measles ; the patches consist of clusters of fine papules or points 
with much surrounding erythema, while normal skin is present between the 



252 



TJie Specific Fevers 



patches. Sometimes the rash is hemorrhagic, minute extravasations of 
blood taking place into the skin ; this may occur in mild cases. It is, how- 
ever, much more common in malignant cases. Purpuric patches are not 
uncommonly found after death that were not present during life. Towards 
the end of the first week the rash, which has been fading for several days, is 
succeeded by desquamation, which is free or slight according to the intensity 
of the rash. This exfoliation of the epidermis generally goes on for many 
weeks, being present longer about the hands and feet. The tonsils are red, 
swollen, and covered with an excess of mucoid secretion, yellow points 
corresponding to the tonsillar crypts are usually present, sometimes there 



piBiig 

HISS 

mm 



imqg 





■HOI 




Fig. 49. — Temperature Chart of a case of Scarlet Fever, medium attack. 

*, Rash present. 



M.K.,aged. 13 years 



are patches of yellow exudation ; the soft palate, uvula, and pharynx are more 
or less congested. The nasal mucous membrane is frequently involved, so 
that there is much discharge from the nose. The deep cervical glands at 
the angles of the jaw are usually enlarged. The tongue is coated with a 
thick white fur ; not infrequently there is a dry glazed central band on the 
dorsum ; in the course of a few days the tongue cleans, leaving a red clean 
glazed tongue with prominent fungiform papillae — i.e. ' the strawberry tongue.' 
The eyes are often suffused and the conjunctivae injected, and with this there 
is often sleeplessness or delirium, no doubt due to a congested state of the 
membranes of the brain. In rare cases the delirium is severe and the 
patient violent. 



Scarlet Fever 253 

The pulse is quick, varying- from 120 to 150, often faster than the temperature 
or the general state of the child would have led one to expect ; the tempe- 
rature varies, mostly reaching 103 or 105 in a moderately sharp attack 
(fig. 49). The urine is scanty, high-coloured, and often contains a small 
quantity of albumen. In the course of a few days, perhaps by the end of the 
third or fourth, the attack has reached its height, and the symptoms begin to 
decline. The rash gradually fades, the temperature falls, the evening rises 
being smaller and the morning remissions more marked ; the tongue cleans, 
the fauces are less injected, and the appetite returns. By the end of the first 
week the temperature has reached normal ; any feverishness which continues 
after this suggests some complication, the commonest being an ulcerating or 
sloughy process going on in the throat, inflammation of glands, and otitis. It 
must, however, be added that attacks of scarlet fever are extremely unequal 
and no two cases are exactly alike. 




Fig. 50. — Temperature Chart of a Mild Scarlet Fever. B. W., aged 3 years. 
Attack contracted in scarlet fever ward. 

Mild Scarlet Fever. — In some cases the premonitory symptoms are 
absent or the fever is only slight and easily overlooked, and the first thing to 
call attention to the attack is the rash. It not unfrequently happens, even 
in hospitals where the children are under observation, that the discovery of 
a rash is the first thing noted. The child may seem to be in its usual health, 
make no complaint of sore throat, and appear to take its meals well, with 
an evening rise and a morning remission of temperature, and yet be suffering 
from a mild attack of scarlet fever (fig. 50). The rash in such cases is rarely 
well marked, but if it is diffuse and punctiform and remains visible for twenty- 
four or forty-eight hours, the attack is unmistakably one of scarlet fever. 
There is usually slight tonsillitis. We have seen a few cases that undoubtedly 
suffered from scarlet fever and infected others, but who never had a tempera- 
ture above 99 Fahr., but had a fairly typical rash. The most difficult cases to 
diagnose are those where there is sore throat without rash, inasmuch as 
there is nothing characteristic about a scarlatinal tonsillitis. 



254 



The Specific Fevers 



Malignant Scarlet Fever. — In some cases death occurs very rapidly, 
perhaps within twenty-four hours, though this is rare. The most rapid case 
which has come under our notice was that of a girl of twenty months. 

Scarlet Fever rapidly fatal.— -She was noticed not to take her dinner well, and vomited 
after her tea ; her temperature, which had been normal in the morning, had risen to 103 
by 5-30 (fig. 51 a); at 7 p.m. the pulse was 160, the tonsils were enlarged, and there was 
a very faint rash over the body ; she was removed the same evening by the resident medical 
officer, Dr. Kershaw, to the fever ward. Next morning the rash had disappeared, the 
tonsils were enlarged with a patch of exudation on one of them, her pulse and respirations 
were rapid, but she did not seem extremely ill. She gradually became worse, the face 
cyanosed, respiration gasping, and pulse failing ; she died soon after 5 p.m., twenty-four 
hours after the initial symptom of vomiting. 




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Fig. 51 a. — Temperature Chart of Malignant 
Scarlet Fever. Death in twenty-four hours. 



Fig. 51 b. — Temperature Chart of Malignant 
Scarlet Fever. Death seventh day. *, Kash. 



At the post-mortem one tonsil was sloughing and soft. Death in this 
case, as in most rapidly fatal cases, took place through the heart failing 
under the influence of the poison ; they may not appear for a few hours in 
actual danger, then symptoms of cyanosis and collapse set in, quickly followed 
by a fatal result. In the great majority of acute cases death does not take 
place till the fourth or the seventh day <fig. 5 1 £) ; in these the temperature 
is high, perhaps 105 or 106 , there is much diarrhoea, often extreme restless- 
ness, followed by coma ; the tonsils are much swollen and covered with foul 



Scarlet Fever 255 

secretion, there is much nasal discharge, the glandular swelling and cellulitis 
are great, the neck being hard and tense to the touch ; the skin is of a dull 
lurid colour, the extremities cold, and the heart gradually fails. If life is 
prolonged for a few days the tonsils and soft palate slough and the lungs 
become the seat of septic pneumonia. In another class of cases in which 
life is prolonged to the end of the second or third week a condition of 
septicaemia is set up. The tonsils ulcerate, sloughy patches appear on the 
fauces, the glands become enlarged and brawny, the nasal mucous membrane 
discharges a purulent secretion, and the conjunctivae become affected ; the 
temperature is remittent but continues high, the urine albuminous, pus wells 
out from both ears, the child gradually wastes, and dies in the course of ten 
or fourteen days. At the post-mortem there are found extensive sloughing 
about the fauces, pleuro-pneumonia, and large hemorrhagic kidneys with 
minute abscesses. In some cases the temperature remains high during the 
second or even third week without any local lesion being discoverable to ac- 
count for it. In all such cases the lungs should be carefully examined, and the 
possibility of some septic inflammation going on in the kidneys should be 
borne in mind. 

Prognosis. — A guarded prognosis must always be given in the case of 
young children, the throat complications in these being generally serious. The 
tonsils are apt to slough, and they have so little power to get rid of the foul 
secretion which rapidly forms in the pharynx and nose that they are extremely 
liable to pneumonia from extension from the pharynx and glandular inflam- 
mation. Diarrhoea is always a serious symptom ; when present at the onset 
it points to a sharp attack, in the later stages it is also of evil augury, and if 
a marked symptom it usually presages a fatal result. Drowsiness at the onset 
and during the course of the attack is an unfavourable symptom, as it usually 
accompanies a high degree of fever and a severe course. In all cases where 
the temperature is maintained during the second or third week the prognosis 
must be exceedingly guarded, and the possibility of a fatal nephritis super- 
vening must be borne in mind. 

Complications and Sequela. — Many of these have already been referred to : 

( 1 ) The tonsils may become deeply excavated, the soft palate may slough, 
a small hole appearing through the velum, to be followed perhaps by an almost 
entire destruction of the soft parts ; in the rare cases when recovery follows, 
cicatrisation and deformity of the soft palate are the result. The inflamma- 
tion may spread to the epiglottis and larynx, and croupy symptoms become 
so urgent that tracheotomy is required. The fauces and larynx may become 
the seat of false membrane. In rare cases the ulcerating process in the throat 
may reach and enter the internal carotid or jugular vein and death follow from 
haemorrhage. 

(2) The nasal and conjunctival mucous membrane may be the seat of 
inflammation or a fibrinous exudation. A chronic discharge from the nose 
and a consequent eczematous condition of the upper lip may be left after the 
fever. 

(3) otitis. — The inflammation may spread along the Eustachian tube to 
the middle ear, and pus be formed in the tympanic cavity, which finds its exit 
by perforation of the membrane. This may happen during the fever or during 
convalescence. We have known it occur as early as the fourth day, in other 



256 



The Specific Fevers 



cases when convalescence is well established. Suppuration in the tympanum 
is one of the common causes of a continued elevated temperature after the 
disappearance of the rash; the child may suffer very little pain, and the pre- 
sence of pus in the external meatus or staining the linen may be the first 
thing to call attention to this complication. At other times the child will put 
its hand to its ear and frequently shake its head, as if to get rid of some source 
of irritation. Pyaemia and abscesses in the lungs may follow if thrombosis of 
the lateral sinus occurs. 

(4) The cervical glands frequently become enlarged and suppurate, 
either during the course of the fever or when the child is convalescent. In 
some cases, more especially in weakly children, much sloughing may go on 
about the neck, deep ragged ulcers being formed, exposing the large vessels ; 
fatal haemorrhage may occur from the latter. 

(5) Broncho- or pleuro-pneumonia occurs very frequently during 
the second week, and is due to extension downwards of the lesion from 
the throat. Pneumonia followed by empyema may take place during con- 
valescence. 

(6) Synovitis and Rheumatism. — The joints are apt to become swollen 
and tender at the end of the first or beginning of the second week ; those 
most frequently affected are the wrists and small joints of the hand, whilst 
sometimes the synovial sheaths of the tendons at the back and in the palms 
of the hands are attacked. The knees, ankles, soles of the feet, elbows, and 
joints of the cervical vertebrae may be affected. Movement of the affected 
joints causes pain, and they are mostly swollen, red, and tender. The affec- 
tion is rarely severe, being fugitive, and seldom returning to the same joint. 
The knees sometimes remain swollen for some weeks from effusion into the 
joints. The cases complicated with synovitis are usually severe, though 
exceptions occur. Peri-endocarditis occurs much less frequently than in the 
ordinary form of rheumatism. Synovitis sometimes occurs in association 
with nephritis during the second week. Attacks of true rheumatism are apt 
to occur during convalescence, but such are more common in young adults 
than in children ; these attacks differ in no particular from ordinary rheu- 
matism, the heart being frequently involved. An attack of scarlet fever 
during convalescence from rheumatism not infrequently causes a relapse. 

Between the years 1880 and 1897, inclusive, 103 cases of synovitis. occurred 
in the 2,840 patients treated at Pendlebury for scarlet fever (3*5 per cent.). 
The following table shows the frequency of this complication in boys and 
girls at various ages : 



Boys 


Girls 


Age in years 


Cases of S.F. 


Cases of 
Synovitis 


Per cent. 


Cases of S. F. 


Cases of i t, 

Synovitis Percent.; 


0-2 

2 -5 

5-10 

10-14 


70 
481 
628 
174 


1 

14 

21 

2 


1 '4 
2 '9 
3 '3 
11 


82 
489 
686 
230 


3 
11 

39 
12 


3-6 

2 - 2 

5-6 

5'2 


Total 


1353 


38 


2-8 


1487 


65 


4"3 



Scarlet Fever 257 

It will thus be seen that joint affections in scarlet fever are more common 
in girls than in boys, in the proportion of 3 to 2 relatively. According to 
the course of the affection this complication of scarlet fever may be divided 
into regular, irregular, and complicated synovitis. 

Regular Synovitis. — Seventy of the 103 cases of synovitis ran a regular 
course, passing off in 53 instances in from two to six days, and only lasting 
beyond ten days in 4 cases. In 41 of these regular cases the synovitis 
came on before the end of the first week, and in 62 before the eleventh day 
of the scarlet fever. The joints involved varied greatly, but in 22 instances 
the hands and wrists only were affected, and in 28 other cases these same 
joints, along with others, were tender and swollen. The frequency with 
which the other joints were affected, either alone or as part of a multiple 
synovitis, was knees 19, ankles 13, elbows 10, shoulders 8, feet 6. Pain and 
stiffness were felt in the back and neck by 9 patients. 

The condition of the sounds of the heart in these regular cases was noted 
as normal 53 times. A temporary apex systolic bruit developed in 15 
cases, from the fifth to the twelfth day of the fever, and persisted varying 
lengths of time from two days to nine weeks, but usually for about seven to 
ten days. In two instances a bruit was present when the case left the 
hospital. As a rule no exacerbation of temperature was noticed to be coincident 
with the onset of the synovitis. In 50 cases the scarlet fever pyrexia was 
prolonged beyond ten days, though it did not often rise above 102. All these 
regular cases recovered. 

Irregular Synovitis. — In addition to the above cases of regular synovitis 
there were 14 (10 girls and 4 boys) which ran a more or less irregular 
course, though all recovered eventually. In 6 cases the joints were not 
affected until after the eighteenth day of the fever, and in 3 instances the 
pains were in the limbs and not limited to the joints. In 6 cases the 
synovitis persisted for periods ranging between twelve and sixty-one days, 
and the pyrexia in the majority of the cases was prolonged to between four- 
teen and 130 days. Three cases were considered to be true rheumatism. 
A temporary systolic murmur developed in 5, and a permanent bruit in 3 
of these cases. 

Complicated Sy?iovitis. — The remaining 19 of the 103 cases were com- 
plicated by serious affections which teminated fatally in 1 1 instances. 
Thirteen cases were below five years of age, and of these 8 died. The 
complications which ended fatally were pyaemia 3, septicaemia 2, cellulitis 1, 
malignant scarlet fever 1, scarlet fever anginosa 1, meningitis 1, and nephritis 
2 ; those which recovered were nephritis with suppuration in foot 1, purpura 
haemorrhagica 1, pneumonia and empyema 1, acute epiphysitis of the right 
femur 1, and synovial suppuration 4. Pus developed in one or other joint 
in 12 of the cases. 

(7) Pyaemia and suppuration in the joints occasionally occurs ; 
any joint may be affected. Such cases are mostly fatal, though not 
invariably so. 

(8) Pericarditis or endocarditis may occur without joint pain or 
nephritis being present. 

(9) Nephritis. — No complication of scarlet fever can vie in importance 
or interest with nephritis ; and this condition often gives rise to much anxiety 

S 



258 The Specific Fevers 

in an otherwise mild and favourable case. The ' initial : albuminuria which 
frequently accompanies the febrile state in the first week of the disease is not 
of much importance, as it is usually temporary and not due to any important 
lesion of the kidneys, and quickly disappears as the fever subsides towards 
the end of the first week. Apart from this febrile albuminuria, there are two 
forms of nephritis which, it is important to bear in mind, are distinct from 
one another, though they have frequently been confounded and much con- 
fusion has arisen in consequence. They may be distinguished as (a) Septic 
nephritis, (b) Post-scarlatinal nephritis. 

(a) Septic Nephritis. — In the severe forms of fever complicated with 
sloughing tonsils and soft palate and much glandular swelling the urine is 
albuminous, frequently highly so ; but it rarely contains blood in appreciable 
quantities or casts ; there are indeed no renal symptoms, or if there are 
they are so masked by the general condition of septicaemia that it is difficult 
or impossible to differentiate them. There is no dropsy or ursemic pheno- 
mena. If the patient survive till the end of the second or third week, a 
more or less typical pyaemic kidney is found at the post-mortem. The 
kidneys are enlarged, frequently very much so ; they are flabby, of a cream 
colour on the surface, with minute haemorrhages and usually minute ab- 
scesses. On section the cortex is of the same cream colour mottled with 
injected vessels and points of fluid or inspissated pus. This condition of 
kidney forms part of a general condition of pyaemia, and is chiefly of interest 
in demonstrating that the kidneys suffer during the course of the disease 
itself, and consequently in cases which recover are in a condition which pre- 
disposes to inflammatory affections during convalescence. 

(b) Post-scarlatinal Nephritis. — This is the form which is liable to super- 
vene during the third or fourth week, and which is known generally by the 
name of scarlatinal nephritis. There can be little doiibt that the kidneys are 
actively engaged during the course of the fever itself, and for the succeeding 
week or two, in carrying off the toxines formed during the fever, and are 
in an irritable condition and prone to take on inflammatory action, in 
the same way as the bronchial tubes and lungs are left in an irritable con- 
dition after measles and are apt to suffer from inflammatory attacks : and 
while it is possible in both cases that nephritis and pneumonia may super- 
vene in spite of the greatest care, yet any chill or exposure to cold is extremely 
likely to produce or determine such an attack. The number of those who 
suffer varies in different epidemics, and also according to the season and 
the care which is taken of them during convalescence. Taking an average 
of several years, we find about 6 per cent, of our hospital patients have 
suffered from post-scarlatinal nephritis. Patients who have had the primary 
fever both in a severe and mild form may be attacked ; in the former class 
of cases, especially where there has been no period of apyrexia, it is mostly 
fatal ; in the latter class — at least in hospital — it is rarely so fatal. The 
prognosis is usually bad in those case's where the temperature continues 
elevated during the second week, in consequence of severe pharyngeal or 
glandular inflammation, and which contract nephritis in the third week, the 
latter complication supervening on the throat lesions. From the fourteenth 
to the twenty- sixth day is the commonest time for nephritis to supervene, 
but as it usually begins insidiously, traces of albumen being present for a 



Scarlatinal Nephritis 



259 



few days before blood and larger quantities of albumen appear, it is often 
impossible to determine the exact date of the commencement of the attack. 
In well-marked cases it is noticed by the attendants that the child which, 
since the subsidence of the fever, has been practically well, becomes restless, 
feverish at night, thirsty, has a quick perhaps hard pulse, and passes small 
quantities of dark-coloured urine. If particular attention has been paid to 
the urine, it will probably have been found that it has been diminishing in 
quantity, and has contained small quantities of albumen for a few days prior 
to the dark urine being passed. Sometimes puffmess about the face pre- 
cedes the appearance of albumen in the urine. The urine may be dark 
red, but usually it is ' smoky,' and on allowing it to stand in a tall glass 
deposits a dark flocculent precipitate, not unlike the flocculi in beef tea. This 
precipitate consists of blood corpuscles, epithelium and fibrinous cylinders 
which have been formed in the tubules and consequently may contain 



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convulsions. Recover)-. 



corpuscles and epithelium. The supernatant liquid contains a variable 
amount of albumen, sometimes becoming almost solid on being boiled ; 
more often a half to a sixth of its volume of coagulated albumen pre- 
cipitates by boiling. It may not contain any blood. For a few days the 
urine continues dark and albuminous and of high specific gravity (1020- 102 5), 
and diminished in quantity, perhaps only a few ounces per diem ; the face 
becomes pale and puffy, there may be cedema of the feet and scrotum, and 
more or less vomiting ; then, perhaps, at the end of a week an improvement 
takes place, large quantities of urine are passed with diminished quantities 
of blood and albumen, and the child becomes again convalescent, though 
the urine may contain some albumen for weeks or even months, and the 
anaemia may continue for a like period. On the other hand, in a minority of 
cases the nephritis is prolonged and symptoms of uraemia may supervene, 
the pulse becomes slow, the temperature subnormal, the tongue dry and 
brown. Often there is frequent vomiting, sometimes diarrhoea (see fig. 52) ; 



260 The Specific Fevers 

haemorrhages may take place from various surfaces, especially the nose ; 
there may be amaurosis, muscular twitchings, and perhaps general con- 
vulsions. 

In all cases of nephritis particular care should be taken to examine the 
heart, inasmuch as a fatal result is more often brought about in consequence 
of cardiac failure than directly through uraemic convulsions. One of the 
effects of nephritis is to raise the tension in the blood-vessels, and this, if 
continued for any considerable time, is followed by dilatation of the heart, 
the tension in the arterial system in combination with malnutrition being 
responsible for this result. Another not uncommon result is endocarditis 
or pericarditis, and possibly embolism. The possibility of death occur- 
ring: suddenly during the course of an acute or subacute nephritis must 
always be borne in mind ; the patient may appear to be doing fairly well, 
perhaps sitting up in bed and playing with his toys, when an attack of 
dyspnoea comes on, the face becomes livid or pallid, the pulse disappears, and 
death quickly takes place. Sometimes attacks of dyspnoea may precede by 
a day or two the fatal event. Such cases have been often described as being- 
fatal in consequence of oedema of the lungs, the dilatation of the heart 
having been overlooked ; oedema of the lungs is present, but it is secondary 
to the cardiac failure. The pathology of such cases is tolerably clear ; acute 
nephritis, running a very rapid course in consequence of the kidneys being 
almost completely choked, usually terminates with uraemic phenomena ; if 
it runs a slower course, the tension in the blood-vessels throws additional 
work upon the heart, the left ventricle struggles with the increased work 
thrown upon it, the blood becomes impoverished and nutrition impaired, 
the cavities of the heart dilate, and finally that organ gives way, often 
suddenly at the last. The amount of dilatation present should be care- 
fully noted by the position of the apex beat, and the increase of impaired 
resonance. 

Pneumonia, pleurisy, and peritonitis may occur in the course of 
nephritis, and pleuro-pneumonia, ending in gangrene, may take place. In a 
few cases the attack is exceedingly acute, the temperature being high, 104 
to 105 , the tongue dry and brown, the urine containing much blood and 
albumen, and death rapidly taking place. In such cases there is usually 
coincident pneumonia. In a large number of cases the attacks are mild, 
a small quantity of albumen, perhaps without any blood, making its appear- 
ance during the third week, the face becoming puffy and the child anaemic, 
the albumen disappearing in the course of a week or two, and the child after 
a prolonged convalescence slowly regaining its health. 

Total suppression of urine is not common, a few ounces daily being 
usually passed ; in one of our cases only three ounces of pale albuminous 
urine was passed in the four and a half days which preceded death ; there 
were no convulsions. Life is rarely prolonged beyond the fifth day if there 
is total suppression. Death takes place in many cases without convulsions ; 
in others convulsions may supervene and recovery follow ; the convulsions 
are not dependent only upon retained urinary products, but also upon the 
stability of the nervous centres, which differs markedly in different children. 
Diagnosis. — The diagnosis of mild cases of scarlet fever often presents 
extraordinary difficulty, and yet the importance of making a diagnosis is often 



Diagnosis of Scarlet Fever 261 

great. In hospital or dispensary practice cases have mostly to be treated as 
infectious or non-infectious ; as there is often no opportunity of taking a 
middle course, they must be sent into a fever ward with the risk of contract- 
ing the disease if the diagnosis is at fault, or of infecting others if treated 
with non-infectious cases. In private practice among the wealthier classes 
it may be possible to isolate all suspicious cases, but such are always a source 
of anxiety. It cannot be too forcibly impressed that diagnosis in some 
instances is impossible, and that errors will occasionally be made by the most 
experienced, though at the same time it must be acknowledged that mistakes 
are more frequently made through carelessness than from any want of know- 
ledge. The most characteristic phenomenon is of course the rash, and if this 
is well marked, being diffuse and punctiform, and lasting at least twenty-four 
or forty-eight hours, even in the absence of tonsillitis or a high temperature, 
there can hardly be a doubt about the diagnosis. Mild cases of scarlet fever 
may occur with a temperature never rising above 99 F. A measles rash 
can hardly be mistaken for it, except in those cases where the rash is patchy 
about the limbs, but in these it is usually diffuse and characteristic on the 
trunk. A scarlet fever rash, however faint, usually lasts for twenty-four hours 
at least, in this respect differing from erythematous rashes, which may be 
present in the evening and gone before morning. It is always well when 
called to see a rash by artificial light to wait for daylight to give a definite 
opinion. It is important to bear in mind that a rash more or less resembling 
scarlet fever occurs in some cases of pyaemia and septicaemia, also in diph- 
theria (which, when it occurs, is septic), influenza, and rubella. A red rash 
is sometimes caused by belladonna, arsenic, and quinine. To distinguish 
between scarlatinal and simple tonsillitis is mostly impossible in the absence 
of a rash ; the 'strawberry' tongue is generally absent in cases unattended 
with a rash. Cases of tonsillitis where the nasal mucous membrane becomes 
involved, or where there is excessive exudation on the fauces or sloughing of 
the soft palate, if diphtheria can be excluded, are probably scarlatinal. If the 
lymphatic glands at the angle of the jaw become enlarged and tender, scarlet 
fever is probable. Acute nephritis occurring after an anomalous rash or 
sore throat makes it practically certain that the primary attack was scarlet 
fever. 

Much importance has been attached in the past to desquamation as 
a means of diagnosis. Now while a typical case of scarlet fever desquamates 
freely, the epidermis separating in flakes from the skin of the neck, trunk, 
fingers, toes, &c, some of the milder cases hardly desquamate at all, the skin 
only becomes slightly roughened ; while on the other hand cases of pneu- 
monia, enteric or any febrile disease, will desquamate more or less. The 
absence of desquamation does not prove that there has been no scarlet fever, 
and the presence of more or less desquamation by no means proves that there 
has been scarlet fever. The presence of desquamation taken in conjunction 
with a history of a sore throat, or associated with nephritis, will materially 
help the diagnosis. 

Morbid Anatomy. — In the bodies o those dying during the first few days 
of the disease, no gross lesions except those in connection with the throat 
can be detected. One or both tonsils are ragged, perhaps sloughy, the glands 
are enlarged, perhaps beginning to suppurate, the internal organs are gorged 



262 TJie Specific Fevers 

with blood, there are minute haemorrhages on their surfaces. The heart, 
liver, and kidneys are pale, the Peyer's glands are swollen, and the mucous 
membrane of the intestines injected. If the child has survived a week or 
more, usually septic changes are present ; the lungs are in a condition of 
pneumonia more or less advanced, which is secondary to the sloughy throat 
and the glandular inflammation and cellulitis in the neck ; marked changes 
are also found in the kidneys if the child has survived two or three weeks. 
In typical cases these are much enlarged, flabby, pale on the surface, with 
minute haemorrhages and injected capillaries ; on section minute abscesses 
may often be seen at the base of the pyramids. On microscopical examina- 
tion large tracts of kidney substance will be found infiltrated with leucocytes, 
and micrococci {Streptococci pyogenes) will be detected in the capillaries. If 
death has been the result of post-scarlatinal nephritis, in the early stages the 
kidneys will be gorged with blood and deeply stained in consequence of the 
tubules being choked with casts and the capillaries distended to their utmost. 
In a later stage the kidneys are enlarged and pale, dripping urine on section, 
and on close examination it will be noted that the Malpighian bodies are 
enlarged and pale, standing out prominently like grains of sand dusted on to 
the cortex. On microscopical examination it will be found that the glomeruli 
are enlarged in consequence of containing an increase in the number of their 
nuclei, in some cases fibrinous thrombi, and in a later stage being surrounded 
by a fibro-cellular growth which completely strangulates them and produces 
complete obstruction. When nephritis is present the cavities of the heart 
are found dilated ; sometimes there is peri-endocarditis, peritonitis, or pneu- 
monia. 

No specific micro-organism has been discovered in cases of scarlet fever, 
yet we cannot doubt that such exists. One of the reasons for its non-dis- 
covery is in all probability that it will not grow on any of the ordinary 
cultivation media. There is no difficulty in cultivating various pus cocci 
from a drop of blood taken from the finger of a scarlet fever patient, but 
this is also true of measles and other febrile diseases. 

Treatme?it. — As soon as scarlet fever is suspected, means must be adopted 
to prevent the spread of the disease in the household by isolating the patient 
as far as it is possible to do so. It is obviously impossible to effect this in the 
smaller class of houses, and indeed even in large and well-appointed houses 
nothing like perfect isolation can be carried out, the removal of the patient to 
a fever hospital being in all cases the wisest course when it can be managed. 
To diminish risks of infection as far as it is possible, a room on the upper 
story should be secured, or, still better, the whole of the top landing should 
be devoted to the patient and those of the household who are in attendance 
on him. Every article in the room which can be spared, especially cur- 
tains, carpets, and other woollen goods, should be removed, only retaining 
such as are required for immediate use. The bedding should consist of a 
horsehair mattress and warm but light coverings. The sick-room should 
be large and airy, the more cubic space the better, provided it can be kept at 
a moderate temperature, and all draughts avoided. The attendants on the 
sick should not mix with the other members of the household, but devote 
themselves entirely to the work of the sick-room. If there are children in 
the house who have not had scarlet fever, the question will arise what is best 



Treatment of Scarlet Fever 263 

to be done with them. In the first place, it is clear that they must not attend 
school or mix with other children ; the question of sending them away must 
depend upon various circumstances. Remaining at home unquestionably 
involves a risk, and at any time so long as the house remains infected they 
may be attacked. Sending them away involves the risk of their being incu- 
bating at the time, and of conveying the infection to another household. 
The best course, if it can be taken, is to send them away to some household 
where there are no children, and whence they can be brought back if they are 
attacked after removal. To send them away to distant seaside lodgings 
could not be sanctioned under any circumstances ; it is better to run the risk 
of infection at home, than have them sicken away from home among 
strangers, and become the source of an outbreak elsewhere. 

As soon as the diagnosis of scarlet fever is made the child should be put 
to bed, and remain there as long as there is fever, or, still better, for three 
weeks, though this, in mild cases especially, is difficult to enforce in private 
practice. In hospital practice three weeks in bed is the ordinary rule ; the 
object of this being to obviate the risk of catching cold, and it is better to 
be over-cautious in this respect. The diet for the first few weeks should 
consist largely of fluids ; it is most important that the digestive organs should 
hot be over-taxed and that the excretory apparatus, especially the kidneys, 
should be active, inasmuch as the waste products are increased during fever, 
and the poison also passes out of the body in this way. During the febrile 
period, milk and barley water or milk and soda water is the best food that 
can be given ; feverish children rarely care for beef tea, and all jellies and 
meat extracts are unnecessary. One or two pints of milk suitably diluted 
during the twenty-four hours will be quite sufficient ; if more is attempted, 
sickness may not unlikely be produced. Daily sponging with tepid or cold 
water, to which some Condy's Fluid or other deodorant is added, is of much 
service. Hot baths are useful during convalescence, but the bath must be 
brought to the patient's bedside. Whilst desquamation is proceeding, 
after the spongings or warm baths the skin should be gently anointed with 
glycerine and starch, weak carbolic oil, or ung. lanolini with carbolic acid or 
eucalyptus. 

We have no belief whatever in the possibility of rendering the patient 
entirely free from infection by anointing the skin. We believe the infection 
of the disease is given out from the nose and throat rather than by the skin. 

The application of topical remedies to the throat and nasal mucous 
membrane is frequently a matter of great difficulty in children, and much 
adroitness and firmness will be often required. In mild cases where there 
is only a slight congestion and swelling of the tonsils, no local treatment 
need be attempted, except perhaps the sucking of pieces of ice or iced milk. 
In older children the throat spray may be used if the patient is sufficiently 
docile, but young children are almost sure to offer a certain amount of 
resistance when their throat is being attended to, and under these circum- 
stances spraying is useless, as the spray is rarely properly directed. Here 
mopping by means of a large paint brush or lint secured at the end of a 
piece of stick will have to be resorted to. Irrigating the mouth and fauces 
is useful in clearing away the mucus and septic matters which are apt to 
accumulate. If there is free discharge of purulent matters from the nose, 



264 The Specific Fevers 

gentle irrigation is of undoubted value, and we think no harm can be done as 
some have stated. 

In selecting an antiseptic which is to be used freely as in irrigating or 
spraying, it is well to remember that some of it may be swallowed, and 
consequently it should not be very poisonous, while for mopping or painting 
a caustic or more active poison may be used. In severe cases the frequent 
cleansing of the throat is a matter of great importance and one upon which 
we are inclined to lay much stress ; it is, however, often attended with 
exhausting struggles for the patient, and can only be done by properly 
trained nurses, the friends rarely having the necessary skill or firmness. 
The actual antiseptic selected is of less importance than the manner of using 
it, the object being to prevent the mucus and products of decomposition from 
accumulating in the fauces and being drawn into the air passages or being 
absorbed. For syringing the nose and fauces a warm solution of boric acid 
(1 in 20), a weak solution of iodine (2 drachms of the tincture of iodine to 
10 ounces), or solution of liq. sodae chlorinatae (1 to 20), answer as well as 
any, and are not disagreeable. For mopping a saturated solution of 
boroglyceride in glycerine, a saturated solution of salicylic acid in sp. 
vini rect., or glycerine acid carbolici (1 in 10) may be used with ad- 
vantage ; it is well to clear away the mucus and purulent discharge before 
mopping the fauces. 

There is but little reason to believe that the course of the fever is much 
influenced by internal remedies ; in mild cases a saline such as citrate of 
potash is useful, giving it in doses of 2 to 5 grs. every four or six hours ; 
chlorate of potash is of doubtful value. In more severe cases the treatment 
must be adapted to the symptoms, stimulants being usually required on account 
of the depression which is so often present. Carbonate of ammonia, digitalis, 
cinchona bark, separately or in combination, are the most useful drugs. 
Diarrhcea, if excessive, must be kept in check by opium enemata ; if moderate, 
it had better be left alone. Sleeplessness, headache, delirium, are best 
relieved by an ice bag to the head and full doses of bromide. We do 
not believe that biniodide of mercury or other mercurial salt is of the 
slightest use in modifying the severity of the attack. It has failed entirely 
in our hands. (F. 46, 47). 

When the temperature continues high, being io4°to 105 , quinine in 1 to 
3 gr. doses, and repeated packs, so as to get the skin to act, have appeared 
to us the most useful form of treatment. The child should be wrapped up in 
a sheet wrung out of water at 6o° and rolled up in a blanket for an hour. 
This must be repeated if the temperature continues high. Cold spongings 
are also useful. In the early stages especially, graduated baths are of great 
value in reducing temperature and soothing the patient. The patient should 
be put into a bath of 90 and the temperature of the bath gradually reduced by 
the addition of cold water. I n the later stages, especially when there is 
blueness about the lips and the heart flagging, more care is necessary, and 
we have seen serious depression produced by a too long use of a cold bath. 
Phenacetin and antipyrin are not suitable for serious cases, on account of the 
depression they are apt to produce. 

The injection of anti-streptococcus serum has been resorted to in cases 
of scarlet fever of the septic type, i.e. sloughing throat and glandular enlarge- 



Treatment of Scarlet Fever 265 

ment ; 10 to 20 c.c. is the usual dose. Successful cases have been reported 
by Mamnoreck and Knyvett. Our own limited experience has not been 
very favourable. Oxygen gas has been used with advantage by Cress well, 1 
and we have been well pleased with it in some cases in which we have 
tried it. 

It must, however, be admitted that the treatment of the severer forms of 
scarlet fever is disappointing and often disheartening ; in spite of the most 
devoted nursing, stimulants freely given, antipyretics, liquid nourishment of 
all kinds, antiseptics to the fauces, they go from bad to worse, apparently un- 
influenced by all that has been done for them. On the other hand, it some- 
times happens that cases which at first are most unpromising are apparently 
saved by careful nursing and appropriate treatment, and this fact should 
encourage every effort. In rare instances sloughing fauces will mend, pneu- 
monias clear up, temperatures which have been high for two or even three 
weeks gradually fall, and complete recovery ensue. 

The otitis which so commonly occurs is usually suppurative from the 
first ; the tympanic membrane quickly gives way and a free discharge follows. 
Earache should be treated by the instillation of warm camphorated oil to 
which a drop or two of laudanum has been added, and hot fomentations 
may be applied externally. A single drop of glyc acid, carbolici (B.P.), 
carefully dropped into the ear so as to reach the membrane, usually gives 
relief. If, on examination with the speculum, pus is seen bulging the mem- 
brane, an incision should be made ; but nature usually anticipates the 
surgeon in this matter, and so quickly that the operation is seldom necessary, 
except in those cases where the membrane fails to give way early. The pus 
which forms in scarlet fever appears to penetrate the membrane more quickly 
than the pus formed in non-febrile cases. When a discharge exists, care 
should be taken to keep the ear syringed out, and some antiseptic powder, 
such as iodoform and boracic acia, blown in. The after-treatment of chronic 
otitis need not be gone into here. 

The preventive treatment of post-scarlatinal nephritis consists in the 
greatest care being taken during the second and third weeks to avoid cold and 
to keep the skin acting, and to avoid a stimulating diet and any overfeeding. 
The child should be sponged daily or bathed, provided there is no risk 
of chill ; the diet should be chiefly fluid, milk, light puddings and sops, and 
the bowels should be acted upon if necessary by laxatives or salines such as 
tartrate of soda or Glauber's salts. On the appearance of albumen a smart 
purge of senna or jalap should be given, and the child dressed in a flannel 
night shirt and placed between the blankets, salines such as citrate of 
potash, liq. ammon. acet, or tartrate of soda, being given. The diet should 
consist entirely of barley water and of milk, or at any rate of fluids. Hot 
packs, a blanket wrung out of hot water being used, or hot vapour baths 
given by means of Allen's apparatus, or warm baths, are always useful in 
acting on the skin and drawing away the blood from the kidneys, and so 
relieving the inflammatory congestion present. The smaller the quantity of 
urine passed the more vigorous should be the packs or baths. Ten grains 
of jaborandi leaves, made into an infusion with hot water, or one-tenth 

1 Practitioner, October 1888. 



266 The Specific Fevers 

of a grain of nitrate of pilocarpine subcutaneously, may be given before 
the packs once or twice a day. Children bear pilocarpine well, but its use 
requires care on account of the cardiac depression it is apt to produce. 
Poultices to the loins should be applied between the packs. Dry cupping 
seems sometimes to be useful and may be tried. If the kidneys fail to act, 
and no urine or only a small quantity is secreted, large enemata of warm 
water will sometimes give relief, urine being passed as the enema is being 
expelled. 

During the course of a nephritis the condition of the heart must be 
carefully watched, as also must any tendency to muscular twitchings about 
the face or hands. Any attacks of dyspnoea or evidence of cardiac dilatation 
must be met by the administration of digitalis, two to five drops every two 
hours. Solution of nitro-glycerine in drop doses, inhalation of chloroform, 
or nitrate of amyl may be tried if convulsions supervene. 

Quarantine. — Six weeks at least — better two months — reckoning from 
the first day of the fever should elapse before a child convalescent from 
scarlet fever can be allowed to rejoin his companions or go to seaside 
lodgings ; and not then if the desquamation is incomplete or there is a dis- 
charge from his nose or ears. In so important a matter as discharging a 
convalescent scarlet fever patient, it is wise to err on the side of caution. 

Experience shows that the scarlatinal infection sticks to the patient with 
extraordinary tenacity, as the number of ' return ' cases to infectious hospitals 
show. Putting aside the question of desquamation (which has probably been 
too exclusively regarded) and also of purulent discharge of ears, it seems 
certain that the infection clings to scarlatinal patients for a considerable 
period, and this in spite of many carbolic baths and much head washing. 
It seems likely that the scarlet fever micro-organisms remain in the 
convalescent's nose and throat long after he is apparently well, and if he 
mixes with his fellows he may infect them. It is not wise to send a patient 
direct from the sick-room or hospital ward to mix with others. Wherever 
it is possible there should be a convalescent ward, and the patient should 
spend many hours in the open air before being looked upon as safe. 

Measles 

Measles is an acute infectious disorder characterised by coryza, cough, 
and fever in the prodromal stage, followed by a peculiar papular eruption on 
the face and body. 

Measles, like whooping cough, prevails in widespread epidemics, though 
its epidemics are of shorter duration ; but sporadic cases are always occur- 
ring" in large centres of population. This epidemic prevalence occurs in large 
cities every eighteen months or two years, though the epidemics differ very 
much in their extent and fatality. 

When once the disease enters a household, or indeed a city street or 
alley, hardly any of the inhabitants escape except perhaps the young infants, 
and those protected by a previous attack ; the chief sufferers are young- 
children. When introduced into the ward of a children's hospital the 
majority of those who are not protected will probably be attacked. Infants 
under six months appear less susceptible than children over that age ; though 



Measles 267 

infants are occasionally born with the rash of measles on them. 1 Communi- 
ties removed from frequent contact with civilisation, and where there has 
been no epidemic prevalent for some time previously, invariably suffer 
severely when the poison of measles is introduced, adults being affected as 
well as children. The most notable instance of this in recent times is the 
epidemic of measles in the Fiji Islands in 1875, w hich raged for four months, 
40,000 natives dying out of a population of 1 50,000,' equal to upwards of one 
in every four of the population, whereas in London in 1886, which may be 
taken as an average year, the deaths from measles were five in every 10,000 
living (at all ages). The same virulence of an epidemic may be seen in a 
lesser degree in populations, more especially among children, in villages or 
isolated places where there has been no epidemic for some time previously. 
The susceptibility to measles is exceedingly great in unprotected subjects : 
thus Biedert, 3 in a small epidemic in an isolated village, found only 14 per 
cent, of the children who were unprotected escaped after being exposed to 
the infection. In the Faroe Islands under similar conditions only 4-5 per 
cent, and 1 per cent, escaped. 4 The same experience obtains in schools and 
in the wards of children's hospitals, where, if a child has been admitted 
incubating and remains till the rash appears, an epidemic follows, which 
it is difficult to stop until nearly all of the unprotected have been 
attacked. The epidemics are independent of season, and occur in winter as 
in summer. 

The disease, like most other specific fevers, spreads by contagion, but the 
nature of this has not been satisfactorily determined, though micro-organisms 
have been. obtained from the breath and secretions of patients suffering 
from measles by A. Ransome, Braidwood and Vacher, and Canon and 
Pielicke. We have frequently made cultivations of pus cocci from the 
blood of patients with measles, and such can also be detected by staining a 
dried drop of blood. 

The poison is apparently given off in the breath and other secretions, and 
may be conveyed to a distance by its adhering to the clothes or person of a 
nurse or others coming in contact with the sick. The infection, however, 
appears to be more diffusible or more readily destroyed than the poison of 
smallpox or varicella, as rarely if ever in our experience is it introduced into 
a ward, except by those who were admitted incubating, it being unlike variola 
or varicella poison in this respect, infection in the latter case appearing to be 
brought in by visitors. The infection is known to be given out from the patient 
very early in the attack — that is, from the first appearance of definite 
symptoms, as coryza and fever — but there is good reason to believe 
that Mr. Vacher is right in believing that measles is infectious during 
the incubative stage, as well as during the febrile and eruptive stages. 
Several instances which point strongly to this conclusion have come under 
our notice. 

The mortality differs enormously according to the circumstances under 
which the attacks develop and also in different epidemics. In healthy 
children among the well-to-do class the mortality is small ; in the tubercular 

1 Helm, Medical Chronicle, May 1890. - Corner, quoted by Collie. 

Jahrbuch fiir Kinderheilkun.de, vol. xxiv. p. 94. * Madsen, Panum. 

'■' Brit. Med. Jour. April 23, 1892. 



268 



The Specific Fevers 



and wasted children to be found in workhouses, hospitals, and among the 
lower classes the mortality is enormous, no disease more certainly being 
attended with a fatal result. William Squire places it at 20 to 30 per cent, 
of those attacked in crowded wards. Among dispensary patients the 
mortality generally amounts to 9 or 10 per cent. In our own dispensary, 
during the six years 1 880-1 885, 1,395 cases were treated, with 128 deaths, 
making a mortality of 9 per cent. Of the fatal cases 73 per cent, were under 
two years of age, and 9 per cent, under six months of age. 

Second attacks of true measles are not uncommon. We know one 
family in which one boy has had a severe attack of measles four times, a 
boy and girl three times each, and one girl twice ; all these attacks were 
severe. In many cases where there is said to have been a recurrence of 
measles, one of the attacks has no doubt been rubella. 



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Fig- 53. — Temperature Charts of cases of Measles. * s rash present. 

Incubation. — When inoculated this appears to be seven or eight days, 
when contracted in the usual way it is mostly ten to twelve days, the rash 
appearing on the fourteenth or sixteenth day. 

Symptoms. Prodromal Stage. — The early symptoms are those of a 
feverish cold. The child sneezes, waters at the eyes, there is catarrh of the 
nasal membrane, with usually a hard, hacking or perhaps croupy cough. 
Sometimes the symptoms are those of a catarrhal laryngitis or bronchitis. 
The palpebral conjunctivas are suffused and of a pink colour from congestion 
of the capillary vessels. The child is feverish, often acutely ill, the tempera- 
ture rising in the evening a degree or two and usually falling again in the 
morning ; this continues though becoming increasingly marked, till the rash 
is fully developed. Sometimes there is a marked remission on the second or 



Measles 



269 



third day (see fig. 54). An examination of the fauces will show that the 
tonsils, hard and soft palate, are reddened, and often distinct papules or red 
points surrounded by a zone of congestion are visible ; in the slighter cases 
these papules are absent. This papular rash is present some twenty-four to 
forty-eight hours before the rash appears on the face and trunk. Koplik 1 
has pointed out that at this stage, that is a day or two before the appearance 
of the external rash, small irregular spots of a bright red colour may be seen 
on the mucous membrane of the cheeks and inside of the lips. In a good 
light a 'bluish white speck' may be seen in the centre of each spot. He 
believes these spdts to be diagnostic of measles. Earache is common during 
the prodromal stage. 




Fig. 54. — Temperature Chart of a case of Measles, complicated with Broncho-pneumonia. 

* rash. 



Eruptive Stage. — The characteristic eruption usually makes its appear- 
ance at the end of the fourth day, on the forehead, face, neck, and 
fauces. The child's appearance at this time is so characteristic that in 
well-marked cases a glance is sufficient to establish the diagnosis. The 
face is flushed, the eyes red and watering, there is a short cough, the fore- 
head, nose, and cheeks are covered with crops of dusky red papules, sur- 
rounded by a zone of erythema which contrasts with the normal skin 
between the groups. The papules can be distinctly seen and felt, and 
though[not ' shotty ' to the touch, yet they have often a distinct feeling of 
hardness. The rash on the face is usually both patchy and discrete, the 
1 Archives of Pediatrics, Dec. 1896. 



270 The Specific Fevers 

patches being made up of confluent papules, the Latter of small groups or 
single papules arranged at times in small crescents or semicircles. In 
the course of a day or two the rest of the body is more or less covered with 
the rash ; it is apt to be confluent with much erythematous redness on the 
dependent surfaces, the extensor surfaces of the arm and thigh, the back 
and buttocks, and more discrete or spotty on the chest and rest of the body. 
By the fifth or sixth day the eruption is at its height, and, beginning 
to fade first on the face and later on the body and limbs, is followed, 
especially on the face, by a fine desquamation. By the seventh or eighth 
the rash has completely disappeared, leaving at most §nly an indefinite 
mottling or staining over the body. The temperature, which has probably 
reached 103 to 105 by the sixth day, quickly falls to normal or thereabouts, 
and the headache and discomfort are gone and the child seems greatly 
relieved. In severe cases in weakly children the crisis may be accompanied 
by much exhaustion, but this rarely happens. The temperature remaining 
high indicates some complication such as bronchitis or pneumonia (see 

fig- 54)- 

Mild or ill-defined Measles. — Very often all the symptoms are milder 
than those just described, but at the same time are perfectly characteristic. 
On the other hand, the attack may be so slight as to be recognised with diffi- 
culty. There may be almost an entire absence of symptoms in the prodromal 
stage, or a temperature only reaching ioo° or 101 , the coryza and catarrh 
being insignificant, while the rash is represented by ill-defined and character- 
less papules about the neck, back of the hands, and thighs. In other cases 
probably the catarrh and laryngeal symptoms are well marked, the child 
evidently suffering from a laryngitis ; this is followed by an indefinite 
mottling about the neck and hands as the laryngeal symptoms abate. 

Severe and Complicated Measles. — Epidemics of measles differ greatly 
in the severity of the individual attacks. Most of these fatal attacks are 
characterised by high fever, dry brown tongue, delirium, and convulsions due 
to an intense hyperaemia of the internal organs, more especially the lungs 
and brain. The heart's action is depressed, the rash ill-defined, the skin 
dusky, and in some cases, markedly petechial. In such cases death may take 
place on the third or fourth day, or improvement may commence at the end 
of a week. In the majority of cases measles threatens life through the 
tendency to inflammation of the lung-s. The lung symptoms may be pro- 
minent from the first, or the presence of pneumonia may delay convalescence 
or supervene when the acute symptoms have passed away. In the former 
case the symptoms are those of acute broncho-pneumonia, the temperature 
continues high, perhaps 105 or 106 , there is marked dyspncea, sibilant sounds 
are heard over the whole chest, the air does not enter the bases freely ; the 
rash is scanty, perhaps only an ill-defined mottling ; delirium followed by 
coma comes on ; the eyelids become glued together with thick semi-purulent 
secretion, sordes appear on the mouth, the tongue is brown and dry, and 
unless improvement takes place the child sinks. 

Catarrhal or Membranous Laryngitis is not uncommon in the pre- 
emptive stage, or as the eruption is receding. Tracheotomy may be required 
if the obstruction to respiration becomes sufficient to threaten life, but it 
must be borne in mind that an amelioration of symptoms generally takes 



Measles 271 

place when the rash appears. In those cases attended with membranous 
exudation the laryngitis generally follows rather than precedes the eruption. 
Ophthalmia frequently occurs in anaemic and unhealthy children ; corneitis 
and corneal ulcers may also be met with. Glandular enlargements 
may develop, the deep cervical gland being especially involved, as in scarlet 
fever ; abscesses are not common. Otitis is very common during con- 
valescence, suppuration taking place in the middle ear and the membrane 
becoming perforated. Diarrhoea is not an uncommon complication or 
sequela, especially during the hot weather, though by no means exclusively 
so : it is apt to become dysenteric in character, mucus, blood, and hard lumpy 
faeces being passed, with prolapse of the bowel. 

The health often remains impaired for a considerable time after an attack 
of measles ; it is during this stage that Acute Tuberculosis and Cancrum 
oris may arise. The tuberculosis very frequently appears to take its rise 
from enlarged and cheesy bronchial glands. 

Diagnosis. — The disease most likely to be mistaken for measles is rubella, 
the latter disease closely resembling mild measles. (See Rubella.) A 
measly rash is sometimes present in cases of septicaemia, where there is 
suppuration as in empyema. 

It is possible to confound measles with smallpox, though this difficulty is 
more likely to arise in the case of adults than children. According to Collie 
there are two kinds of smallpox which it is possible to confound with measles, 
viz. the commencement of a confluent case and the commencement of a haemor- 
rhagic case. The papules in smallpox are much harder and more shotty, 
and, moreover, in a confluent case, the headache, lumbar pain, and general 
symptoms would be more severe. Haemorrhagic measles is very rare, and, 
according to the same author, would be difficult to diagnose from ' black 
smallpox;' the quantity and quality of the vaccination marks should be 
taken into account. 

Morbid Anatomy. — There is not much to be said under this head, inas- 
much as there are no post-mortem appearances characteristic of measles, 
the principal lesion found being catarrhal pneumonia ; the whole of the 
internal organs are gorged with blood, and minute haemorrhages are present 
on their surfaces. The mucous membrane of the bronchi is intensely con- 
gested, the surface of the pleura roughened and perhaps covered with lymph, 
one or both bases being solid from catarrhal pneumonia ; in such case the 
pneumonia resembles that found in septicaemia. In some instances croupous 
pneumonia involving a lobe or portion of a lobe may be present, or there 
may be patches of croupous pneumonia. At other times there is intense 
bronchitis, with patches of catarrhal pneumonia and emphysema. In all 
cases of pneumonia following measles which we have examined micro- 
scopically we have found fibrinous exudation in the air vesicles, in spite of 
the pneumonia being apparently of the catarrhal variety. A fibrinous exuda- 
tion is sometimes found on the mucous membrane of the arge bowel. 

The following post-mortem record taken from one of our note books 
illustrates a malignant case :— 

Measles, malig7iant case; death. — Child of eleven months; death on fourth day. 
On removing lungs it is noted that the upper lobes are emphysematous on their surfaces ; 
in the lower lobes emphysema alternates with collapse ; on section there is intense 



272 The Specific Fevers 

injection of the trachea and bronchi, yellow mucus exudes from the minute bronchi ; 
the lungs are intensely congested, there are patches of broncho-pneumonia in the lower 
lobes. 

Treatme?it. — No very active treatment is needed during an attack of 
ordinary severity, but much may be done to promote the patient's comfort and 
to prevent any complications. He should, of course, be confined to bed as 
soon as measles is suspected, the temperature of the room being maintained 
at 65 F., and if the cough is hard and irritating a steam kettle should be 
called into requisition to keep the atmosphere moist. The diet should con- 
sist of milk diluted with barley water or seltzer ; in mild cases sops or light 
puddings may be allowed. Demulcent drinks, such as barley water, lemonade, 
black currant or tamarind drinks or jellies, are useful in allaying the irritating 
cough. Frequent spongings with warm water containing a weak solution 
of tar or ' sanitas ' relieve the itching and help to bring out the rash. During 
the pre eruptive stage, when there are high fever, restlessness, cough, and 
frequent pulse, small doses of tr. aconiti, one or two drops every two hours 
— carefully watching the effect, especially after five or six doses have been 
given — will be usually attended with relief. Jelly containing codeia or small 
doses of Dover's powder may be given to relieve the cough. Great care 
should be exercised during convalescence to prevent catching cold, especially 
in those who are liable to bronchial catarrh, as the bronchial mucous mem- 
brane remains for some time in an irritable condition, and exposure to cold 
is exceedingly likely to give rise to bronchitis or diarrhoea. 

In cases of greater severity, especially those in small children which are 
accompanied by a scanty rash, congestion of the internal organs, high tem- 
perature, and broncho-pneumonia, active treatment is required. It is neces- 
sary to get the skin to act efficiently and thus relieve the congested internal 
organs ; to this end tepid sponging, hot packs, or mustard baths may be 
employed. For children under two years of age the mustard bath is the 
most suitable ; the child being placed for three minutes in a bath of ioo° F., 
one table-spoonful of mustard to the gallon of water being about the proper 
strength. The child must be quickly dried and put between blankets ; the 
bath may be repeated in a couple of hours if necessary. The stimulating 
effect of the bath upon the skin is often of great service. Linseed poultices 
to the chest are to be avoided in the case of young children, unless the 
attendants are trained nurses ; hot fomentations or bran poultices are pre- 
ferable in dispensary practice and in the hands of the unskilled, as being less 
heavy. 

In older children the hot pack is to be preferred to baths. In the early 
stages small doses of antimony, pot. ant. tart. ^-^ of a grain, with some 
tartarated soda or citrate of ammonia, should be given every three or four 
hours, but omitted if there is nausea. Aconite may be useful, but it must be 
carefully watched, on account of the depression it is apt to produce if 
pushed too far. Alcohol in the form of whisky or brandy should be given if 
the pulse is small and rapid and the tongue dry and brown. If the cough 
becomes loose and there is excessive secretion from the bronchi, ammonia, 
digitalis, and alcohol in combination should be given. The eyes, nose, 
and mouth in severe cases require attention ; they should be bathed or 
mopped out with warm water ; if there are any aphthous patches in the 



Measles — Ru bella 273 

mouth some borax in dilute glycerine should be applied. Otitis and glan- 
dular inflammation may require attention. During convalescence no medicine 
answers better than nitric acid and bark. (F. 48, 49). 

Quarantine. — How long should quarantine be maintained in a case of 
measles ? This is not an easy question to answer, though it is certain that 
the infection is not given off from the patient for so long a period as is the 
case in scarlet fever. In uncomplicated cases hot baths may be given as the 
rash begins to disappear ; they are useful to cleanse the skin and render 
the patient more comfortable. It is well for the patient to keep his bed for ten 
days and his room for three weeks ; then, if he is quite well in every respect, 
there can be little danger in his mixing with his fellows. When a case of 
measles occurs in a house, it is necessary for the other children who have 
not had it to stop going to school or mixing with other children, as it is 
probable they will have contracted the disease ; and as measles is infec- 
tions in its early stages — if not during the incubation period — they may 
readily be the means of giving it to others. For the same reason it is un- 
wise to send them away from home, though care should be taken that they 
do not come in contact with the patient at home. The bedding should be 
stoved and the room occupied by the patient disinfected at the conclusion of 
the illness. 

Rubella 

Rubella 1 is an infectious fever closely resembling but distinct from 
measles ; it is for the most part a milder disorder than measles, and does not 
protect from it. In some epidemics it closely resembles mild scarlet fever. 

Etiology. — The resemblance between these two diseases is unquestion- 
ably a close one, and there is little doubt that not infrequently epidemics of 
rubella — or at any rate sporadic cases — are mistaken for measles. It has, 
however, been clearly shown by those who have had the opportunity of 
watching successive epidemics of infectious diseases in schools and asylums, 
where the same individuals have been attacked, that rubella does not 
protect from either measles or scarlet fever, nor do attacks of the two latter 
afford any immunity from attacks of rubella. The resemblance, and yet the 
difference, between the two diseases was well put by the late Dr. West when 
he said 'they resemble each other somewhat as varicella and variola — alike, 
but not the same — not twin sisters indeed, but half-sisters at any rate.' 
That they should be confounded in practice is not surprising, especially 
when we remember that measles is sometimes an extremely slight disease 
and the rash by no means characteristic. In mild attacks of measles the 
coryza is usually slight or absent, and the rash little else than ill-defined 
mottling. 

Rubella occurs in epidemics, sometimes being prevalent and widespread, 
as it was in this country during 1880 ; at other times sporadic cases crop up 
and there appears but little tendency for the disease to spread. As a result, 
rubella has earned a different character as regards contagiousness from 
different writers who have observed it, some maintaining that its contagious- 
ness is almost nil, and others that it is extremely contagious. The truth is 

1 We adopt the term rubella as first suggested, we believe, by W. Squire. ' Epidemic 
roseola,' which has been proposed, introduces the ambiguous term of ' roseola.' 

T 



274 The Specific Fevers 

that susceptibility to its influence seems to vary strangely at different times 
and in different places in a way which it is difficult to account for. Thus in 
one locality there may be an epidemic prevalent ; an individual g"oes to 
another while incubating, he suffers from an ordinary attack and the disease 
does not spread, though he comes in contact with many individuals. There 
is little doubt, however, that rubella has been confounded with some of the 
non-specific, non-contagious forms of roseola or rose rash. Age does not 
seem greatly to influence predisposition ; infants, children, and adults suffer- 
ing alike ; indeed, in some epidemics adults suffer more in proportion to 
their numbers. Thus in an epidemic in the Children's Hospital observed 
by Dr. Hutton and ourselves, out of twenty-seven cases, eight were those of 
lady probationers or ' sisters,' and nineteen of children ; so that the adults 
suffered far more largely in proportion to their numbers, though there can 
be no doubt that the nurses came in contact with those suffering from the 
disease much more than the children. Considering how much rarer a dis- 
ease rubella is than measles, it would appear that a smaller number of 
individuals who are unprotected by a previous attack are susceptible to its 
influence. 

The relationship of rubella to measles and scarlet fever is an interesting- 
question, and while very few believe it to be a hybrid disease, the attack 
resulting from the reception by the patient of both scarlatinal and measles 
poisons, yet, considering the close resemblance which it bears to measles, 
there is nothing inherently improbable in the idea that the resemblance is 
something more than coincidental, that the poisons may have been derived 
from one another or from the same stock at some distant epoch, and have 
become modified by being cultivated under different conditions. It is inter- 
esting to note that some observers assert that the character of an epidemic 
becomes modified in the direction of either measles or scarlet fever if either 
of these is prevailing at the same time. 

It is a curious fact that there are epidemics of rubella, in which the rash 
closely resembles scarlet fever and not measles, as is generally the case. 
Whether the two forms are distinct diseases or only varieties of the same 
disease, it is impossible to say. We cannot say whether the measles variety 
protects from the scarlatinal variety. 

Incubation. — There has been some uncertainty about the length of the 
incubation period. The common period is from two to three weeks, as observed 
both by W. Squire and Lewis Smith. In three cases coming under our own 
observation the time appeared to be sixteen, seventeen, and eighteen days 
respectively. 

Premonitory Stage. — In children, as a rule, no prodromal symptoms are 
observed, the rash being the first thing to be noticed. In adults who are 
able to describe their feelings, complaint is made of weariness, headache, and 
backache for twenty-four hours before the appearance of the rash. There 
may be vomiting, coryza, slight sore-throat, or a tingling sensation of the 
skin of the face. Another noteworthy symptom sometimes present is the 
enlargement of the superficial lymphatic glands situated along the posterior 
edge of the sterno-mastoid, or the submaxillary and occipital glands are 
tender as well as slightly enlarged, and give rise to a certain amount of 
stiffness of the neck. On the other hand, it is by no means uncommon even 



Rubella 275 

in adults that the discovery of a rash is the first thing to call attention to the 
attack. 

Prodromal Stage. Measles variety. — The rash usually appears first on 
the face, and consists of indistinct, ill-defined papules, forming irregular 
patches of a rose-red colour, which shade away into the colour of the skin ; 
there may be simply erythematous blotches. The patches of confluent 
papules vary much in size and shape, many perhaps consisting of only a few 
papules grouped together ; sometimes, on the contrary, the whole face is of 
a red colour. The rash is usually also abundant on the neck, chest, back, 
buttocks, and flexor surfaces of the arms and thighs ; in these situations it 
is usually less confluent and patchy than on the face, the rash consisting of 
groups of papules or of single papules. Occasionally the confluence of the 
papules and the erythema which surrounds them give rise to the suspicion of 
scarlet fever, especially to that form in which the rash is patchy on the limbs, 
but the rash of rubella always consists of papules, and is not diffuse or punc- 
tated as is the rash of scarlet fever. Rubella rashes undoubtedly vary con- 
siderably, especially in the confluence of the papules ; as a rule, the colour 
is of a rose-red when it first comes out, being of a brighter colour than 
measles ; the papules do not so constantly arrange themselves in crescents, 
and they are less distinct than the measles papules. The rash is usually most 
intense on the second day, but remains visible for three or four days ; by 
the end of this time it has mostly faded, often leaving more or less staining 
of the skin and a light branny desquamation. The rash frequently gives 
rise to much itching. Sometimes the axillary and inguinal glands become 
enlarged. 

The course of the attack may be feverless, though usually there is a slight 
rise of temperature, the highest being on the second day, 99 to ioo° ; in rare 
cases it reaches 102 or 103° The temperature becomes normal as the rash 
disappears. 

Hyperemia of the conjunctiva and fauces exists in many cases, but it is 
rarely as marked a feature of the attack as it is in measles. Sometimes a 
dryness and soreness of the throat in swallowing is complained of, with more 
or less catarrhal tonsillitis. 

While such may be taken as a typical attack, it must be acknowledged 
that the attacks of this exanthem vary greatly in intensity, and the rash may 
be too ill defined to admit of a positive diagnosis. In some rare cases, such 
as those described by Dr. Cheadle, the course of the disease is that of a serious 
illness, with marked implication of the larynx and bronchi, the cough being- 
incessant and crouplike. In two of these broncho-pneumonia supervened, in 
several others earache was a prominent symptom. On the other hand, cases 
may occur of the mildest form, so wanting in character both as regards rash 
and coryza, that they may be looked upon as of a doubtful nature and perhaps 
forgotten, and only when they are succeeded by more typical cases does 
their character become clear. 

Scarlatinal variety. — Some years ago we were much puzzled by finding 
that a number of what were apparently mild cases of scarlet fever, when 
admitted to our fever ward developed scarlet fever a few days after their 
admission. Shortly after we noted a number of patients coming to the out- 
patient department with diffuse red rashes, but who were hardly ill at all, 

t 2 



276 The Specific Fevers 

but had been brought on account of the rash. It soon became apparent 
that there was an epidemic of a disease closely resembling scarlet fever yet 
distinct from it, inasmuch as it left the patient still susceptible to an attack 
of scarlet fever. This epidemic was no doubt one of the scarlatinal variety 
of rubella. In many of the cases there was a history of vomiting as an 
initial symptom, complaint of sore throat, slight fever, and a very well-marked 
rash, while the child hardly felt ill at all. The rash was usually copious, 
and could not be distinguished from scarlet-fever rashes, but was more of a 
rose tint, and less distinctly punctiform in character — that is, there was a 
uniform redness without the red points which correspond with the hair 
follicles being well marked. Still, we must admit that the rash seen in 
these cases was indistinguishable from some undoubted scarlet-fever rashes. 
When once such an epidemic is known to prevail the diagnosis ceases to be 
difficult. The fever, malaise, and sore throat are slight, while the rash is copi- 
ous. In scarlet fever with a copious rash the fever is usually high, the tonsils 
are angry and swollen, and the child is evidently ill. Mild cases would not 
be likely to occur one after another ; some would be certain to be sharp and 
typical. Desquamation follows the red rash of rubella, but it is rarely as well 
marked as in typical cases of scarlet fever, where the rash has been copious 
and the fever sharp. Some authors lay great stress on the enlargement of 
the lymphatic glands behind the sterno-mastoid, axilla, and inguinal region. 
This is no doubt true, but they are not universally enlarged ; we have 
certainly seen cases of both varieties of rubella without any lymphatic 
enlargement. In some cases and in some epidemics the rash is more 
patchy than the rash described, but we have not seen many such. It must 
be borne in mind that the scarlatinal variety of rubella is a comparatively 
rare disease, while scarlet fever is a very common one, and that an isolated 
case of fever with sore throat and a diffuse red rash is far more likely to be 
scarlet fever than rubella, however mild and uncomplicated it may prove to 
be. To find that a child we have declared to be suffering from ' German 
measles' has acute nephritis, is, to say the least of it, an unpleasant dis- 
covery. 

Rose rashes, diffuse and patchy, may make their appearance after the 
ingestion of some improper food, or in hot summer weather. There is usually 
an absence of both sore throat and fever. The possibility of a. red rash 
being due to belladonna must not be forgotten. 

Complications a?zd Sequela. — There are usually none ; in the more severe 
cases catarrhal disorders, such as coryza, tonsillitis, and broncho-pneumonia 
may complicate and succeed the attack. The prognosis is favourable ; the 
disease is probably never fatal in healthy children ; in epidemics in hospitals, 
where it attacks children already suffering from and much reduced by 
pulmonary affections, it has appeared to be the immediate cause of a fatal 
result. Even in healthy children the health may remain below par for 
some time afterwards. 

Diagnosis.— Rubella may at times be mistaken for some of the anomalous 
erythematous or roseolous rashes from which children suffer from various 
causes, especially indigestible food ; but there is usually no fever. In single 
cases diagnosis may be difficult, but the fact that rubella prevails in epidemics 
often assists in making a diagnosis. The diagnosis between measles and 



Rubella 



277 



rubella in an individual case is at times impossible ; often it is difficult, 
inasmuch as it must be admitted that there is no one characteristic symptom 
of rubella, and moreover the rash differs in different cases. The differences 
between typical cases of rubella, measles, and scarlet fever are shown in 
the table below. 

Treatment. — Every case of rubella and every suspicious case should be 
carefully isolated, and confined to one room, if not to bed. The diet should 
consist largely of fluids and slops. A simple saline such as citrate of potash 
may be given, and other symptoms must be treated as they arise. 

Quarantine. — The patient should be isolated for at least three weeks ; 
better if four weeks elapse before he is allowed to rejoin his companions 



— 


Rubella 


Measles 


Scarlet Fever 


Incubation. 


14 to 21 days. 


8 to 12 days. 


2 to 5 days. 


Premonitory fev. 


1 day. 


3 to 4 days. 


1 day. 


Prodromal sym- 


Often none. Sometimes 


Sneezing, coryza, 


Vomiting, headache, 


ptoms. 


enlarged glands, 
weariness and slight 
coryza. 


headache, cough. 


sore throat. 


Tonsillitis. 


Slight tonsillitis. 


Usually none. 


Tonsillitis well 
marked. 


Rash. 


Appears on the first or 


Appears on the 


A diffuse punctiform 




second day. Con- 


fourth or fifth clay. 


red rash comes 




sists of indistinct 


Consists of conflu- 


over neck, trunk, 




papules of a rose-red 


ent papules of a 


and limbs — may 




colour confluent on 


dusky red colour 


be patches on the 




the face, usually dis- 


011 the face, and 


extremities. 




crete on the limbs, 


groups of papules 






buttocks, and thighs. 


often in a crescen- 






Often fades from the 


tic form on the 






face before it is fully 


trunk and limbs. 


- 




developed elsewhere. 








Often much itching. 








In the scarlatinal va- 








riety the rash closely 








resembles scarlet 








fever. It is rose- 








red, diffuse, less 








markedly puncti- 








form than typical 








scarlet fever. 






Desquamation. 


Desquamation absent 


Desquamation ab- 


Desquamation usu- 




or only very fine 


sent or only in fine 


ally free. 




branny scales. 


scales. 




Temperature. 


Often normal through- 


Fever always pre- 


Fever always pre- 




out, rarely above 


sent, sometimes 


sent, mostly high, 




ioo° F. 


high, reaches its 


disappears as the 






maximum when 


rash fades. 






the rash is fully 








out, then falls. 





278 The Specific Fevers 



CHAPTER XV 
the specific FEVERS — {continued) 

Diphtheria 

Diphtheria is an infectious disorder which is characterised by the for- 
mation of a fibrinous exudation on mucous surfaces or abraded skin, due to 
the growth of a specific bacillus ; it is usually accompanied by anaemia and 
albuminuria, and frequently followed by paresis of various muscles. At the 
very threshold of the subject it maybe as well to attempt to clear the ground 
by asking — Are we to consider all fibrinous exudations which have the 
characters of a ' false membrane ' as evidence of the presence of diphtheria ? 
Is diphtheria always accompanied by a 'false membrane'? Both these 
questions must be answered in the negative. Recent observations clearly 
show that other micro-organisms besides the D-bacillus are capable of pro- 
ducing fibrinous exudations on the fauces, and, moreover, the D-bacillus has 
been demonstrated in the secretions taken from non-membranous sore 
throats. Stilly we must admit that membranous exudations are usually 
diphtheritic, and that diphtheria is not often present in the absence of 
' false membrane.' 

That diphtheria is a highly contagious disorder is made certain by very 
definite evidence ; it is a matter of common experience that the disease 
passes from patient to nurse, from one patient to another in the wards of a 
hospital, and from a sick child to its playmates or parents in private houses. 
It is certain also that the infection can be conveyed from the sick to the 
healthy by means of a third person, the infected particles travelling on the 
clothes or on the hands of the latter. The occurrence of diphtheria in the 
families of medical men who were attending cases of diphtheria is a proof of 
this. Direct inoculation has taken place accidentally by means of small 
pieces of membrane or the secretions entering the mouth, as in sucking a 
tracheotomy wound ; false membrane has formed within twenty-four hours 
of an operation at the seat of the wound. The disease is often spread' in 
schools and families by individuals who are not ill enough to be laid up, 
going about while suffering from mild and unrecognised diphtheria. There 
is little doubt also that the disease has been transferred from animals to 
man through direct contact or by means of milk from cows suffering from 
the disease. The D-bacillus may retain its vitality for many months out- 
side the body, and may be carried any distance in clothes, bed linen, or on 
surgical instruments. It is possible, though we believe unproven, that the 
D-bacillus may grow and develop in sewage, in cesspools, and drains, and 



Diphtheria 279 

re-enter the body by the inhalation of sewer gas. It is a popular notion 
that there is a close connection between diphtheria and sewer gas, and 
sanitary faults in houses are frequently credited with being the cause of 
outbreaks of diphtheria ; and it is quite possible that sewer gas may give 
rise to a non-specific sore throat which may form a suitable soil for the de- 
velopment of the D -bacillus. 

Diphtheria occurs in epidemics, but it is also endemic in some cities and 
rural districts. It is constantly present in such cities as Berlin, Paris, and 
New York, and in some rural districts in this country. In its distribution 
and in the varying character of its epidemics it is one of the most mysterious 
diseases with which we are acquainted, and there is much about it which 
requires continued investigation. In this country until recently it has been 
more common in the rural than in the urban districts, though it appears at 
the present time to be more common now in our large towns than formerly. 
It is especially prevalent in the south-eastern and eastern rural districts, 
while some others appear to escape almost entirely. It makes its appear- 
ance at times in isolated farmhouses, or villages remote from other habi- 
tations, and this circumstance has suggested the idea that possibly the 
infective particles have been conveyed thither by means of the wind (Airy). 
It has occurred in Central Africa far away from any source of infection. 
But in connection with these singular cases we must remember that the 
D-bacillus retains its vitality for many months under suitable conditions, 
and may be conveyed any distance on clothes or other articles, and thus 
infect persons long distances away from the original source of the infection. 

Xo age is exempt from its attacks, but children between the ages of two 
and eight years are most often attacked, and children of these ages more 
readily succumb than do older children. The disposition to diphtheria 
seems to run in families, members of the same family being attacked in 
quick succession or at variable intervals. 

The parts which are most often attacked are the fauces, nasal mucous 
membrane, larynx and trachea, glans penis and vulva ; less often some wound 
or eczematous skin. The bacillus enters the mouth in either air or food, 
and if conditions are favourable for its development the growth of the 
bacillus commences, and membrane forms on the tonsils and soft palate. 
In what these favourable conditions consist it is difficult to say. Cer- 
tainly a slight sore throat or laryngeal catarrh often precedes an attack 
of diphtheria, and it is very probable that any injury to the epithelium or a 
catarrhal state may afford a suitable soil for the development of the bacillus. 
We have known instances in which nasal diphtheria has supervened in a 
case of chronic ozaena, while other children exposed to infection at the 
same time were not attacked. The fatality of different epidemics varies 
strangely : sometimes whole families are swept away, as in the epidemic 
described by Trousseau in Sologne, where in one farm, where the residents 
numbered eighteen, only two, the father and a sen-ant girl, survived. The 
infection seems to vary in intensity, at times and under certain conditions 
becoming attenuated, at other times resuming its virulency. 

Morbid Anatomy and Pathology. — The membranous exudation which is 
present in diphtheria is of a whitish-grey colour, and when first formed is 
firmly adherent to the tissues beneath it. It is in some cases rather yellowish 



280 The Specific Fevers 

than white ; in malignant cases it is frequently brown from being stained 
by broken-down blood. In a few days more or less the membrane becomes 
loosened from its attachment and can be removed by means of a brush : if 
forcibly removed it leaves a raw surface, which quickly becomes again 
covered with membrane. Speaking generally, membrane adheres more 
firmly and is less easily detached from the mucous membrane of the tonsils 
and soft palate than from the larynx and trachea. If a thin section of a 
piece of membrane adhering to the soft palate be stained with methyl 
blue, and examined with a moderately high power, it will be seen that the 
membrane consists of a fine network of fibrin with epithelial cells and 
leucocytes in the meshes ; beneath the membrane the papilla? and connective 
tissue of the deeper layers of the mucous membrane will be seen to be in- 
filtrated with leucocytes. Loeffier's D-bacilli are to be seen usually in little 
balls or masses embedded in the superficial layers of the false membrane ; 
in some cases they may be seen in the deeper part of the membrane or 
beneath it. Unlike the anthrax bacillus, the D-bacillus remains local, 
and does not penetrate into the tissues or enter the blood. The D-bacillus 
is a non-motile little rod about the length of the tubercle bacillus, but 
thicker, so that when several are joined together they look at first sight not 
unlike streptococci. When fully developed the ends of the bacilli are 
darker and thicker than their central portions ; sometimes only one end is 
enlarged. Two are often joined together. They vary considerably in shape 
and size, according to their age and the conditions under which they have 
grown ; thus the ' long bacillus ' and the ' short bacillus ' are sometimes 
spoken of ; it would be unsafe to say that the presence of the short variety 
means a mild attack of the disease. Recently, chiefly by French authors 
(Roux, Yersin, Barbier, Sevestre), the micro-organisms which are found 
associated with the diphtheritic bacilli have been carefully studied. The 
most important association is with streptococci, the strepto-diphtheria of 
French authors ; these cases correspond with the septic cases of scarlet 
fever, with which, indeed, they have a close resemblance. The presence of 
streptococci in considerable numbers notably increases the virulence of the 
attack. Staphylococci (aureus and albus) are frequently associated with the 
D-bacilli, the attack is usually more benign than when streptococci are 
present. Pneumococci (Frankel), Coli-bacilli, Proteus bacilli may also 
be present, the latter in gangrenous diphtheria. The chemistry of the mem- 
branes and the poisons formed in the exudations and in the blood have been 
studied by Roux and Yersin, and more recently by Sidney Martin (Lancet, 
March 26, 1892). The latter observer has established the fact that during 
the growth of the bacilli a ferment is formed which is capable of digesting 
proteids, certain albumoses being formed which act as virulent poisons on 
the system. These albumoses are formed locally and are then absorbed into 
the blood ; but it appears the ferment is also present in the blood, and by 
its action on the proteids of the blood and tissues albumoses may be formed 
in the spleen and other organs. Similar poisons are formed when the 
bacilli are cultivated in blood serum or in gelatine. Roux and Yersin have 
shown that if the nutrient fluids in which the bacilli have grown are, after 
the bacilli have been separated by filtration, injected subcutaneously into 
guinea pigs, death takes place with symptoms of toxaemia in twenty- 



Diphtheria 281 

four hours. If small doses were employed and injected into rabbits, and a 
fatal result did not take place, a paralysis was often left. The poison 
appears to give rise to degeneration of the tissues ; there are changes in the 
fiver cells, the muscular fibres of the heart and other organs, and the smaller 
motor and sensory nerves. In the peripheral nerves the white substance 
of Schwann undergoes degeneration, and in places disappears ; the axis 
cylinder is also affected, but in less degree. It is this peripheral degenera- 
tion of the nerves which is the cause of the paralysis so often noted after an 
attack of diphtheria. The blood is profoundly altered, and its coagulability 
interfered with ; hence the haemorrhages and purpuric condition seen in 
malignant cases of diphtheria. The cause of the albuminuria is uncertain ; 
it may be caused by the altered state of the blood, or be due to the fatty 
degeneration which the renal epithelium undergoes ; the amount of albumen 
present is in most cases a correct index of the severity of the attack. 

From the above facts it would appear that the D-bacillus is the 
primary infective agent, and that during its growth it gives rise to the 
fibrinous exudation ; at the same time a ferment is formed resembling pep- 
sine which is capable of digesting proteids. This proteid digestion goes on 
both in the membranous exudation and also in the blood, albumoses being 
formed, which play the part of virulent poisons, giving rise to rapid tissue 
degeneration and serious changes in the blood. The relation between the 
diphtheria of man and that of the domestic animals is interesting and im- 
portant. Some of our domestic animals appear to suffer not infrequently 
from diphtheria, and may be the means of giving rise to epidemics of human 
diphtheria. The observations of Klein ' have shown that diphtheria may be 
communicated to cows by subcutaneous injections of cultivations of bacilli 
from the membrane taken from cases of human diphtheria. A soft tender 
swelling forms at the seat of the injection, and in some cases at least a 
number of pimples appear on the udders, which pass through the stages of 
pustules and ulcers. The cows suffer more or less from fever, and an exten- 
sive loss of hair takes place. During the eruptive stage the milk of some 
of the cows was found to contain numerous diphtheria bacilli. In at least 
two epidemics of diphtheria in which the milk coming from a certain dairy 
was suspected of being the cause, it was found on examination of the cows 
that they were suffering from an eruptive disorder on their udders similar to 
that produced in those cows which had been inoculated. Diphtheria has 
been produced by Klein in cats by feeding them with cultures of the D-bacillus 
in milk, and epidemics of diphtheria have been observed in cats. Guinea 
pigs are the most susceptible of all the domestic animals. Fowls suffer from 
membranous croup which closely resembles, if it is not identical with, human 
diphtheria. 

Pharyngeal Diphtheria. — The tonsils, uvula, and pillars of the fauces 
are the favourite sites for the false membrane in diphtheria, and in by far 
the greater number of cases occurring in practice these parts are affected in 
the first instance. The attack, unlike scarlet fever, usually begins insidiously. 
The friends notice that the child is ailing, it does not care for its toys, it is 
peevish and fretful, and towards evening is feverish. Perhaps there is some 

1 Twentieth annual report of the Local Government Board. 



282 The Specific Fevers 

glandular enlargement at the angles of the jaw, or a discharge from the 
nose, or the child is heavy and drowsy. In older children there is usually 
some complaint of sore throat or difficulty in swallowing ; the child feels cold 
and shivery, and sits over the fire trying to keep itself warm. An examination 
of the fauces, if made within a few hours of the first symptoms, may show 
nothing very distinctive ; there may be some swelling and excessive redness, 
with some whitish or yellowish exudation in points or patches, but it may be 
quite impossible to decide whether the case is one of diphtheria, scarlet 
fever, or other form of tonsillitis. Usually, however, within twenty-four hours 
of the commencement of the illness, patches of membranous exudation may 
be seen on the inner surfaces of the tonsils or soft palate ; these are whitish 
or grey and opaque, adhering firmly to the surface so that they cannot be 
removed by brushing. If removed by forceps, a raw bleeding surface is left ; 
a piece of membrane when removed is seen to be tough and firm, differing 
from the soft cheesy material which is present in scarlet fever or tonsillitis. 
The temperature is rarely high, being mostly ioi° to 103 F. ; the evening- 
temperature being, as a rule, a degree or two higher than the morning tem- 
perature. In a day or two, if not from the first, membranous exudation may 
be seen on the uvula or the pillars of the fauces, though the tonsils may be 
from first to last the only part affected. The nasal mucous membrane is apt 
to join in the inflammatory process ; a semi-purulent, often bloody discharge 
makes its appearance at the nostrils ; the child makes a snoring noise when 
asleep, on account of the obstruction caused by the swelling of the mucous 
membrane and the excessive secretion. An examination of the urine during 
the first day or two may be negative as far as albumen is concerned, but if 
a daily examination be made, in the great majority of cases albumen vary- 
ing in amount from a trace to one-half will be found. During the next few 
days fresh patches of membrane make their appearance on the fauces, the 
older ones becoming loosened, then detached, by the process of sloughing 
which goes on. In the meantime the glandular enlargement and tender- 
ness become more marked, and the neck is stiff and all movements are 
painful. The patient becomes weak, anaemic, and easily exhausted ; there is 
often marked fcetor of the breath. In favourable cases, after the first few 
days or a week no new membrane forms, while the old patches disappear, the 
swelling of the glands and tonsils becomes less, and the temperature gradually 
falls. The albumen also gradually diminishes in quantity and finally dis- 
appears. The child remains weak for a long time, convalescence being only 
slowly established. On the other hand, in unfavourable cases, instead of an 
improvement taking place at the end of the first week, the symptoms both 
local and general become more pronounced ; the amount of urine increases, 
the pulse is weaker and perhaps intermittent, the anaemia is profound, the 
breath very offensive, and oozing of blood takes place from the mouth and 
nose. The patient gradually becomes exhausted and refuses his food. 
During the last hours of life there may be total suppression of urine, drowsi- 
ness, and extreme depression of the heart's action. 

Mild cases may occur in which both the local and general symptoms are 
slight. There may be membranous or yellow-coloured patches on the tonsils, 
the nasal mucous membrane remaining free and the glandular enlargement 
absent, and perhaps only a trace of albumen in the urine. Such patients 



Diphtheria 283 

may be seen running about with but little appearance of illness ; the local 
lesions may disappear in a few days. It is important to remember that in 
such cases paralysis may follow, or a fatal result may come about through 
cardiac failure. 

ivialiernant Diphtheria. — Of severe and malignant cases of diphtheria 
there are several types. The attack may begin insidiously with a day or two 
of slight illness, and then alarming symptoms of cardiac failure may set in 
without there having been any excessive local lesion. In other cases the attack 
is stormy from the very first, perhaps accompanied by vomiting, and closely 
resembling scarlet fever in its mode of attack (strepto-diphtheria or septic- 
diphtheria). Within a few hours of the onset there is extensive swelling at 
the angles of the jaws, with a feeling of stony hardness, a foetid, sanguineous 
discharge issues from the nostrils, and it is difficult to get a view of the 
throat in consequence of the swelling and difficulty in opening the mouth. 
The tonsils are so swollen as to meet, the uvula and soft palate cedematous 
and covered with more or less sloughy-looking membrane. The temperature 
is usually high, being 103 to 104 F., and the pulse and heart's action 
exceedingly feeble. In the course of a day or two, sometimes less, the 
cellulitis extends, the cheeks and face become cedematous, and the skin pits 
as low as the clavicle, or even over the sternum and chest walls ; the patient 
becomes drowsy and cyanotic, and there may be an erythematous rash, 
especially about jthe neck and chest. Purpuric rashes are common in 
malignant cases. Death usually occurs in a few days. Such cases resemble 
malignant scarlet fever, and it may be difficult or impossible to distinguish 
between them in the absence of a characteristic rash. 

Nasal Diphtheria. — In pharyngeal diphtheria the inflammatory pro- 
cess is apt to spread to the nasal mucous membrane, especially in severe 
cases. In some cases, however, the nasal mucous membrane is the first 
seat of the exudation, and it may never spread to the tonsils, though it is 
usually to be found to involve the back of the soft palate and the pharynx 
more or less. In nasal diphtheria no membrane may be distinguished 
during life ; there may be only a purulent discharge with blood, the presence 
of which in the nasal passages obstructs respiration, giving rise to a bubbling 
or sniffling sound, especially during sleep. In nasal diphtheria the general 
symptoms are usually quite as severe as in faucial diphtheria, and a guarded 
prognosis must always be given. In cases in which the soft palate, 
tonsils, and nasal mucous membrane are involved, the general symptoms, 
including the depression and also the albuminuria, are well marked. In 
connection with this form of diphtheria we must bear in mind there is a 
form of membranous exudation occurring on the nasal mucous membrane 
in measles and as a primary disease which is not diphtheria, but which runs 
a much more favourable course, and in some cases at least the membrane 
formed is thinner and less adherent than it is in diphtheria. The term 
' Rhinitis fibrinosa ' has been applied to these cases. In all cases in which a 
child is feverish with a discharge from the nostrils we should be exceedingly 
suspicious of diphtheria, especially if an epidemic prevails at the time. The 
inflammation may spread from the nose to the conjunctiva, and membrane 
may form on the palpebral conjunctiva and much purulent discharge may 
exude, while the eyelids may be much swollen. Membranous conjunctivitis 



284 The Specific Fevers 

is not usually diphtheritic, but due to pneumococci (Frankel) ; the local dis- 
turbance may be severe, while the constitutional symptoms are slight. 

laryngeal Diphtheria. — The larynx may be the seat of the local mani- 
festations of diphtheria in the first instance, or may become involved 
secondarily to the fauces or other part. The child may in the first place 
suffer from sore throat and feverishness for several days, and then a metallic 
cough and some dyspnoea will suggest the onset of laryngeal complications. 
Less often some other part is the first to be involved ; thus we have known a 
patch of membrane to make its appearance at the seat of an eczema, and 
then a few days afterwards a diphtheritic laryngitis supervene. The sym- 
ptoms present in laryngeal diphtheria will be found described (p. 332). We 
must constantly bear in mind that the obstruction to the air passages caused 
by the presence of membrane in the larynx or trachea may modify or over- 
whelm the symptoms of the disease, but we must not overlook the tendency 
to heart failure or the depression, as well as the possibility of uraemia or 
paralysis supervening. 

Wound Diphtheria. — diphtheritic membrane may be present on the 
lip, tongue, vulva, and glans penis. The diphtheria bacillus is, however, 
apparently unable to flourish on normal skin ; but when the cuticle is 
abraded, as after blistering" or in eczematous conditions when a moist raw 
surface is present, the bacillus readily flourishes. Granulations also afford a 
congenial soil. The bacillus may be inoculated during an operation — as, for 
instance, in excision of the tonsils ; we have seen a case in which membrane 
formed within twenty-four hours of an operation for hypospadias at the seat 
of operation, a fatal result occurring in a few days. We have several times 
seen membrane form on granulations at the external wound in empyemata. 
In one of these cases a fatal result followed. In tracheotomy for diphtheria 
the wound and skin around the wound are apt to become the seat of a 
fibrinous deposit, the inoculation taking place by the sputa coughed through 
the tube. In newly born infants the granulating surface left after the slough- 
ing of the cord may become the seat of a diphtheritic inflammation. 

Complications- and Sequela. — These, though less numerous than those 
occurring after scarlet fever, are hardly less important. There is the ex- 
tension of the inflammatory process from the fauces to the neighbouring 
parts already referred to — viz. to the larynx, nose, middle ear, and lymphatic 
glands ; the latter may suppurate besides these. The most noteworthy are 
the following : 1st, albuminuria and uraemia ; 2nd, pneumonia ; 3rd, disturbed 
innervation of the heart ; 4th, paralysis. 

1. Albuminuria can hardly be said to be a complication of diphtheria, 
inasmuch as it is almost constantly present at some time or other of the course 
in faucial, nasal, and laryngeal diphtheria. It is, however, frequently absent 
in mild cases of wound diphtheria. In some epidemics, according to some 
observers, albuminuria is much commoner than in others. Our experience 
certainly has been that albumen is rarely absent from the urine in cases of 
true diphtheria. The albumen usually makes its appearance from the third 
to the eighth day. The urine is mostly normal in colour and in amount, but 
a few blood corpuscles and epithelial casts may be found on microscopical 
examination in many cases. In some malignant cases hematuria may be 
present. The amount of albumen present forms a rough indication of the 



Diphtheria 285 

severity of the case ; at least after the disease has existed for a few days. 
The albuminuria is due to the changes effected in the blood or in the renal 
epithelium of the kidney by the albumoses or toxalbumens present in the 
blood, and the amount of albumen in the urine represents to some extent 
the amount of poisoning going on. Suppression of urine and uraemia 
occur at times, though the symptoms present are not so distinctive as in 
scarlet fever, as death mostly takes place before the symptoms become well 
marked. Persistent vomiting with a falling temperature should always 
suggest uraemia ; the urine may become scanty and loaded with albumen, 
and perhaps cease to be secreted twenty-four or forty-eight hours before 
death. (Edema, muscular twitchings, or uraemic convulsions are rare. In 
cases which recover traces of albumen may remain for months, but chronic 
kidney disease as a result of diphtheria is uncommon. 

2. In severe cases of diphtheria, pneumonia in the catarrhal form is 
common, and is the result of an extension of the inflammation from the 
fauces or larynx to the lungs. It is found in nearly all cases of fatal laryn- 
geal diphtheria. It is often haemorrhagic. 

3. In all severe cases at the height of the attack the pulse is feeble and 
for the most part rapid. It sometimes happens at this time that the heart's 
action becomes irregular, intermittent, or abnormally slow. This condition 
is, however, more common during convalescence, or at least when the mem- 
brane is disappearing and the patient apparently improving. There is often 
dyspnoea on the slightest exertion, an intermittent cantering action of the 
heart, and frequently vomiting. Sudden cardiac syncope is apt to take 
place. This may occur from any unwonted mental disturbance or from 
some slight exertion, such as getting out of bed or sitting up to use the 
chamber vessel. With an irregular action of the heart there is often dyspnoea ; 
frequent vomiting and slow pulse during convalescence from diphtheria are 
symptoms of great gravity. 

4. A peculiar form of paralysis is apt to follow not only diphtheria, but 
also other febrile disorders, as typhoid fever, measles, and erysipelas ; it is, 
however, very much more common after diphtheria. The paralysis comes 
on in the majority of cases during convalescence, mostly between the third 
and fifth weeks ; it appears to follow mild cases as often as it does severe ones. 
Its usual course is to attack the soft palate, the first symptoms being a return 
of fluids through the nose, perhaps only a few drops, and a nasal twang in 
speaking ; an examination of the soft palate shows that its movements are 
less free than usual. In many cases a slight paresis of the soft palate, which 
may pass off in the course of a week or two, is the only evidence of post- 
diphtheritic paralysis. In other cases the paresis is much more decided ; when 
the patient attempts to swallow any fluid, much of it returns through the 
anterior nares, and some may perhaps enter the glottis, giving rise to a fit of 
choking: Other parts may become affected — the pharyngeal muscles and 
oesophagus, so that deglutition is performed with difficulty and the patient 
has to be fed through a soft catheter. The pupils may become dilated and 
unequal from paresis of the circular fibres of the iris, there is impairment 
of vision, from the ciliaris muscle being affected. The paresis may extend 
to any or all of the voluntary muscles, so that the patient is unable to stand 
or sit up in bed or even raise his head. Further, the respiratory muscles, 



286 The Specific Fevers 

the intercostals, and diaphragm may be affected, in most instances speedily 
producing a fatal result. The movements of respiration are laboured, the 
patient cannot give a forcible cough or cry or speak loudly. It must be 
borne in mind that in post-diphtheritic paralysis there is rarely complete 
paralysis, but rather a partial loss of power, combined with numbness and 
sensations as of prickings with ' pins and needles.' Both rectum and 
bladder may also become paralysed, but this is not common. It is important 
to bear in mind that paresis may follow very mild cases, so that the patient 
may be seen for the first time when suffering from the paresis and make no 
mention of sore throat. Such cases, especially if there be no paresis of the 
soft palate, may be very puzzling, and, if there be weakness of the legs and 
staggering gait, may be mistaken for tumour of the cerebellum or ataxy. 
The knee reflex is absent in such patients, and it may be many months 
before it makes its reappearance. 

Diagnosis. — The diagnosis of diphtheria in a typical case does not present 
much difficulty, especially if an epidemic is prevailing. The false membrane 
on the fauces, and the presence of albumen in the urine, render the diagnosis 
of diphtheria practically certain. But there may be a fibrinous exudation on 
the fauces with more or less fever ; no urine can perhaps be obtained, or, 
if obtained, it may contain no albumen, and we may be in doubt about the 
diagnosis. There may be a membranous exudation on the tongue, lip, nasal 
mucous membrane, or conjunctiva, with no marked constitutional symptoms, 
and we may be in doubt as to the nature of the case. In such cases clinical 
distinctions may entirely fail us, it being uncertain if the case in question is 
one of mild diphtheria or not. We have to depend for a diagnosis on the 
detection of the D-bacillus in the membrane or secretions. If we can 
by microscopical examination or by cultivation in blood serum demonstrate 
the presence of Lceffler's D-bacillus in the membrane, the diagnosis is 
certain ; if, on the other hand, only streptococci or staphylococci are present, 
the case is not one of diphtheria. In cases of ' croup ' or ozaena an examina- 
tion of the secretions, which may be non-membranous, may often decide the 
diagnosis in favour of diphtheria. The disease of the throat most likely to 
be confounded with diphtheria is croupous or membranous angina ; usually, 
however, in this disease there is no tendency to spread to the nasal mucous 
membrane or the larynx, and there is less often glandular enlargement. 
The onset is more sudden ; the urine is free from albumen. It is unnecessary, 
perhaps, to add a word of caution in not excluding diphtheria without very 
good reason. No albumen may be present in the urine at the time of 
examination, but be present later ; there may be a complete absence 
of constitutional symptoms, and yet diphtheria be present. A mild case of 
diphtheria in a household may be followed by a malignant one. Diphtheria 
is distinguished from scarlet fever by the absence of the rash, though an 
erythematous blush is present in a few cases. In malignant strepto-scarlet 
fever the rash may be absent, and the glandular swelling and sloughy 
condition of the throat closely resemble diphtheria ; there may also be a 
fibrinous exudation as well as albuminuria. Diagnosis is often impossible. 
The punctiform rash, however, is rarely absent in scarlet fever. 

Progjiosis. — Diphtheria is one of the most fatal diseases with which we 
have to deal ; but the mortality differs widely in different epidemics. The 



Diphtheria 287 

most fatal form is undoubtedly the laryngeal ; but the mortality has been 
considerably reduced by the use of antitoxme. Strepto-diphtheria in its 
worst forms is exceedingly fatal. Of especially bad augury are large 
quantities of albumen in the urine, much glandular enlargement, ex- 
cessive nasal discharge, a foetid state of the fauces, vomiting, and suppres- 
sion of urine. A sudden fall of the temperature to subnormal, and an inter- 
mittent pulse, are also extremely bad symptoms. Recovery from a severe 
attack in which there is great depression and much albumen in the urine is 
exceptional, especially in a child under six years of age. Suppression of 
urine in diphtheria is nearly always fatal ; though in one' case seen by us, 
in which the boy had suppression of urine and nasal haemorrhage, recovery 
finally took place. A fall of temperature in scarlet fever in the absence of 
nephritis is a good sign ; it is by no means so in diphtheria, especially if 
vomiting be present and an increasing quantity of albumen. 

The mortality of cases of diphtheritic paresis is very high in those cases in 
which the diaphragm and intercostals are affected. Cases in which the 
paresis is confined to the limbs, soft palate and muscles of the eye mostly 
recover. Those patients who live five or six weeks after the onset of the 
paralysis mostly do well. 

Treatment. — The indications for treatment are the following : 1st. To 
isolate the patient in the most airy room obtainable. 2nd. To antagonise 
the poisons absorbed into the system or formed in the blood. 3rd. To apply 
antiseptics to the fauces or affected parts to prevent decomposition and fcetor. 
4th. To support the strength of the patient, and to treat symptoms as they 
arise. 

1st. The patient may be isolated by sending him away to a hospital for 
infectious diseases, and this is often the best and simplest plan, but it is not 
always possible. If the patient is to remain at home, the largest room 
available on the top landing should be selected, or, still better, two rooms 
adjoining one another, so that the patient can be moved from one to the 
other, thus allowing the unused one to be ventilated. The supply of a large 
quantity of fresh air to the patient is of the first importance. All other 
children in the house should be sent away, bearing in mind, however, that 
they may be incubating the disease, so that they should not be se?it where 
there are other children, or to a distance where they ca?inot be brought back 
again in case they fall sick. Arrangements should be made for disinfecting 
all the excretions and bed linen of the patient. 

2nd. The most important therapeutical procedure in connection with 
diphtheria is to inject antitoxic serum. No time should be lost as soon as 
ever the diagnosis is made, as statistics clearly prove that it is within the 
first two or three days that the antitoxin exerts the greatest control over the 
disease. It is wise to use fresh serum, as after a year or less the serum appears 
to lose strength rapidly by keeping. The usual strength of the serum at 
present on the market is 1,000 units per c.c. ; the average dose for a child 
above two years of age is 1, 500 units. In a severe case, 2,000 units should be 
injected. The best place is the skin of the flank ; the skin in this situation is 
less sensitive than it is on the abdomen. The surface must be thoroughly 
washed with soap and hot water, a suitable syringe, such as Roux's, sterilised 
by boiling^ a fold of skin nipped between the fingers, and the serum injected 



288 The Specific Fevers 

into the subcutaneous tissues. The dose should be repeated in twelve or 
twenty-four hours. The injection is sometimes followed by a rise of tempera- 
ture, but in twenty-four hours the temperature falls, the membrane tends to 
separate, and the patient feels better and is brighter. It is the pure diph- 
theria cases in which the effect is most marked, while the septic or strepto- 
diphtheritic, in which there is much sloughing- of the throat and cellulitis, 
are but slightly influenced or not at all. In cases of diphtheria which have 
lasted a week or more, the improvement is small or nothing ; we have seen 
such cases die within a few hours of the injection without the slightest 
improvement being manifested. It is certain that the injection of serum 
cannot cure the mischief which has already been done by the disease, and 
in malignant cases irreparable and fatal mischief may occur within twenty- 
four hours of the commencement of the attack. In any case, but little good can 
be expected in a severe case if the injection is delayed three or four days. The 
pain and discomfort of the injection have been materially lessened by the intro- 
duction of the concentrated serums of a strength of 500 or 1,000 units per c.c, 
as a smaller needle can be used, and there is less fluid to be injected. It 
is less common now than it was a year or two ago to find erythematous rashes, 
urticaria, and swelling of joints following the injection. We have never seen 
a case in which the antitoxin was followed by any alarming symptoms when 
used early in the attack ; when used in severe cases, and late in the disease, it 
is only too likely that if death quickly follows after the injection the fatal 
result may be attributed to it. Experience teaches that, in children under 
two years of age, the serum treatment is just as useful as it is in older 
children. The experience of physicians, both in Amerca and in Europe, is 
greatly in favour of the serum treatment, and there can be little doubt that 
the mortality of the disease has been lewered by its use. It is difficult to 
express this accurately in statistics, as it is well known that epidemics of 
diphtheria differ extremely in severity, and the mortality with the serum treat- 
ment differs largely according as to whether it has been used within the first 
day or so, or late in the attack. Then, as we have already remarked, the 
serum injection has little or no effect on septic cases, and these in some 
epidemics form the majority of the cases. The prophylactic dose for 
children is 500 units, the serum being used for this purpose in hospitals, 
schools, and households more frequently on the Continent and in America than 
it is in this country. If children are to remain in a household in which a case 
of diphtheria is being nursed we should certainly advise their being injected. 
3rd. During the last few years it has been recognised that our means 
of destroying specific organisms present in the throat and naso-pharynx 
are extremely limited. The action of antiseptics contained in sprays or 
local applications is too temporary to effect much, and can hardly reach 
bacilli which are embedded in membranous exudation or are subepithelial. 
The most we can effect is to keep the throat and fauces sweet and clean. 
It is evident also that we have in the serum treatment a far more powerful 
means at our command to control the disease than by any local applications. 
In many cases, especially in young children, the prolonged fight rendered 
necessary in order to cleanse the naso-pharynx is extremely exhausting to the 
patient. Warm boric acid or potass-permang. irrigations, as recommended 
in the treatment of scarlet fever, are, if they can be applied effectually, useful 



Diphtheria 289 

in cleansing the throat by removing mucus and foetid secretions. The 
insufflation of powders such as precipitated sulphur, boric acid and iodoform, 
may generally be managed without difficulty. In many cases, on account of 
the fractiousness of the patient, we must be satisfied with vaporising" carbolic 
acid in the sick-room by means of heat or by a Siegel's steam spray placed 
near the patient's face. For wound diphtheria dry applications, as finely 
powdered calomel, are much more efficient than lotions or ointments. With 
regard to the medicinal treatment of diphtheria, we prefer to use the 
old-fashioned tr. ferri perchlor. in three to five minim doses every four hours. 
It may be given in lemonade, soda water, or in any way in which the 
patient will take it. We do not think that either chlorate of potash or 
bichloride of mercury is the least use, and in large doses they are dangerous. 
For the treatment of the paresis, hypodermic injections of strychnine and 
inhalation of oxygen should be employed, if the heart or respiratory muscles 
show any sign of weakness. Digitalis, caffeine, coca wine, alcohol, should 
be given from the first if there is much depression of the system, and in the 
worst cases alcohol in the form of brandy or port wine must be given with a 
free hand. 

4th. The diet supplied to the patient must consist of the most concen- 
trated form of nourishment possible, as in most cases there is great difficulty 
in getting him to take food on account of the discomfort and pain in swallow- 
ing ; beef juice, peptonised meat preparations, milk, and nutrient supposi- 
tories may be needed. If there is swelling or cellulitis, the neck should be 
painted with glycerine and belladonna and covered with cotton-wool. If the 
glands suppurate, incision and proper drainage must be resorted to. The 
greatest care must be exercised during convalescence to supply the patient with 
suitable food and fresh air, and to prevent any exertion on his part. Paresis of 
the soft palate, general paralysis, and failure of the heart may come on at 
any time within a month or five weeks of the commencement, even in mild 
cases, and the practitioner should constantly be on his guard, and warn the 
friends against allowing any excitement or unwonted exertion. During con- 
valescence quinine, strychnine, and iron should be given. The continuous 
current and massage is of use in the paralysis which follows. Change to the 
seaside after five or six weeks, reckoned from the commencement of the 
attack, will prove of great benefit. 

Quarantine. — This should be maintained for four weeks in mild cases, 
and six weeks or more in the more severe attacks. It is important during 
convalescence to spray or irrigate the patient's throat and fauces with weak 
carbolic or boric acid solution in the hope of getting rid of any remaining 
bacteria, and to allow the patient to be in the open air as much as he can. 
If possible a bacterial examination of the secretions of the patient's fauces 
should be made before letting him loose on society. 

Disinfection. — A temperature of 6o° C. in a moist atmosphere is sufficient 
to destroy the D-bacillus. For disinfection the simplest way is to boil the 
linen removed from the patient, and treat his clothes, as far as possible, in 
the same way. The furniture of the rooms in which he has been should 
be scrubbed with hot water and carbolic soap, and the floors and walls 
should be treated in like manner. Wearing apparel which cannot be boiled 
had best be destroyed. 

TJ 



290 The Specific Fevers 

Membranous non-diphtheritic Tonsillitis 

Practitioners have long been familiar with a form of sore throat which 
mostly occurs in epidemics, which in many ways resembles diphtheria, but for 
the most part runs a milder course, and is not followed by the serious 
sequehe which so often follow diphtheria. Such cases have gone by the name 
of diphtheritic sore throat or 'croupous angina.' Recent observations have 
shown that the D-bacillus is not the only micro-organism which is capable of 
giving rise to fibrinous exudations, but, at the same time, no other micro- 
organism is apparently able to produce the depression, albuminuria, and 
paralysis which so often accompany true diphtheria. Given suitable con- 
ditions, several kinds of cocci, especially the Streptococcus and Staphylococcus 
pyogenes, the colo?i bacillus, and the pneunweoccus of Frankel are able to 
produce an inflammatory sore throat with more or less fibrinous exudation ; 
there is also, according to Klein, a 'pseudo-diphtheria bacillus' closely 
resembling the true bacillus in its histological characters, but incapable of 
generating during its growth the toxic albumens produced by the true 
bacillus. We are, however, inclined to agree with those who look upon the 
pseudo-diphtheria bacillus as the true diphtheria bacillus which has lost its 
virulence. Cases of pseudo-diphtheria may be mild with only slight fever, 
but, on the other hand, they may commence with vomiting, high fever, 
rigors, and the tonsils may be swollen and covered with a membranous 
exudation. The mortality is not high, being very much less in diphtheria, 
but fatal cases do occur, sometimes from pneumonia. The clinical course of 
such cases may be very much like what has already been described under 
acute tonsillitis. Fibrinous exudation may occur in other places, as on the 
nasal mucous membrane, tongue, lip, vulva, conjunctiva, in connection 
with measles or other diseases, caused by septic cocci as well as by the 
D-bacillus. 

The one important point in connection with these cases is necessarily the 
diagnosis. If we can certainly exclude diphtheria, the relief to all concerned 
wall be great. Clinically this may be impossible, and a diagnosis may only 
be made by demonstrating the absence or presence of the D-bacillus in the 
exudation or secretions. But difficulties may occur here as long as the 
question as to the existence of a pseudo-diphtheria bacillus, and its dia- 
gnostic characters, is unsettled. It must be remembered that the failure to 
find the D-bacilli in the secretions of a sore throat is only negative evidence. 
The local treatment of pseudo-diphtheria is much the same as that for 
diphtheria, antiseptics being employed to destroy the cocci and to keep 
the fauces and mouth sweet. Carbolic acid, salicylic acid, peroxide of 
hydrogen, and chlorine water are among the most suitable. On the skin, 
starch and salicylic acid powder answers very well. All such cases should 
be isolated ; indeed, every case of tonsillitis occurring in children should be 
regarded with suspicion, and kept away from its fellows during both the 
febrile and convalescent stages. 

Epidemic Influenza. * La Grippe ' 

During the last few years the British Isles, in common with the con- 
tinents of Europe and America, have been, visited by epidemics of a peculiar 



Epidemic Influenza 291 

zymotic disease, which has received various names, but is best known in 
this country as ' epidemic influenza.' These epidemics have been wide- 
spread, affecting a number of people at the same time, have come to an end 
in a few months, and then reappeared in the following year. Epidemic 
influenza is very infectious, its incubation is short, and, unlike most zymotic 
diseases, one attack does not protect from attacks in subsequent epidemics. 
It is very prone to relapse. In some epidemics in past times children appear 
to have escaped to a large extent, having been apparently less susceptible 
than adults. This does not seem to have been so in the recent epidemics, 
for individuals of all ages have been promiscuously attacked, children having 
been affected in common with adults, though the mortality among the former 
has not been so high as among the latter, especially in the pneumonic form. 
In some epidemics children have apparently escaped till late in the epidemic. 
The incubation is usually a short one, often not more than a few hours, 
though it may be longer. Certainly instances occur in which a very few 
hours after the arrival in a household of an infected individual some members 
of the household are quickly attacked. The disease appears mostly to 
spread by direct contagion, and the difficulty of controlling an epidemic 
arises from the fact that a number of mild cases occur which do not confine 
the patient to his bed or to the house, so that while going about his business 
as usual he readily disseminates the disease. R. Pfeiffer has successfully 
cultivated the influenza bacillus on blood-agar — that is, an agar medium 
containing haemoglobin. The bacillus occurs in large quantities in the 
mucus coughed up. 

The difficulty in describing the symptoms consists in the absence of any 
very characteristic ones, and in the multiplicity of symptoms which may be 
present. Moreover, the type of attack appears to alter from time to time 
and in different localities. The diagnosis has, in point of fact, often to be 
made by a process of exclusion, aided greatly by the knowledge that an 
epidemic of the disease is prevailing at the time, and that perhaps other 
members of the household have recently suffered. As a result of the difficulty 
of diagnosis, there cannot be a doubt that many cases in which the diagnosis 
was doubtful have been described as influenza, inasmuch as the disease was 
prevailing at the time ; and thus it has come to pass that much confusion has 
arisen, and much that has nothing to do with influenza has been included in 
the descriptions of this Protean disease. We are far from denying that 
influenza may not be the cause of diverse forms of inflammatory lesions ; 
we know the so-called pneumonia diplococcus is able to excite not only a 
pneumonia, but also an otitis and meningitis, and it is by no means impossible 
that the influenza micro-organism may at one time excite a pneumonia and 
at another time an enteritis or meningitis. The cases in which the greatest 
difficulty in diagnosis occur are in infants and young children. It is so 
tempting to attribute an indefinite febrile attack in an infant to teething or 
dyspepsia, and so difficult to be certain that the attack is due to influenza, 
unless another case crops up in the same household to give us the clue. In 
infants we have not the advantage of the patient's account of himself as we 
have in adults, so that the diagnosis is often only come to with difficulty. One 
of the commonest forms of the disease in infants and young children is the 
simple febrile type. Practically the only prominent symptom is fever. The 



292 The Specific Fevers 

infant is noticed to be hot, there is a temperature of 102 or 103° F., the 
pulse and respirations are accelerated, it is heavy and drowsy, and then, after 
a few days or a day or two, the temperature falls, and the infant is prac- 
tically well again. In many cases the course is protracted, the temperature 
going up every evening for a week or more before it finally settles down to 
normal again. In more severe cases the fever suddenly runs up to 104 or 
105 (it maybe with a convulsion or vomiting), then for days or weeks there 
may be fever of a remittent or intermittent type, without there being any 
pneumonia or tubercle or enteric fever to account for the temperature. 
Finally, a good recovery is made. These cases are often very puzzling, 
especially the protracted ones, and we may call in question our original 
diagnosis of influenza, and begin to fear there may be an acute tuberculosis 
in progress : in all such cases it is, of course, necessary to repeatedly examine 
the lungs, and to bear in mind the possibility of an erratic enteric fever being- 
present ; there cannot be a doubt, however, that in young children a fever 
of the intermittent type, lasting two or three weeks or more, may be due to 
the influenza bacillus. Convulsions and vomiting are among the frequent 
symptoms in infants and young children, possibly suggesting an acute 
meningitis ; the vomiting is often exceedingly troublesome at times, but 
the worst cases of this type occur in older children. In others there may 
be bronchitis and pneumonia of a depressing and fatal character. We 
have not seen many fatal cases in infants apart from pneumonia, but in 
one case that we know of death occurred in two days as the result of 
an attack which was accompanied by high fever and depression. The 
infant was ten months old and its mother was suffering from influenza at the 
time. 

In older children the attacks approach more nearly the types of attacks 
witnessed in adults. But as a general rule the neuralgic pains are less 
marked, as also are the rigors and backache. The attack is sudden, the 
temperature rurning up to 103 or more, there is severe headache, vomiting, 
chilliness, and often sore throat. The conjunctivae are injected and the 
child has a heavy look. Earache is often a marked symptom. After twenty- 
four or forty-eight hours of more or less high fever, the temperature falls to 
normal or it runs a lower course. Some cough remains for a few days, and 
often marked depression ; but this, in our experience, is not so severe as in 
adults. An examination of the fauces will often show them to be injected, 
and the tonsils enlarged and covered with yellow points ; there may be some 
glandular enlargement secondary to the tonsillitis. To add to the difficulties 
of diagnosis, these cases sometimes have a red rash closely resembling- 
scarlet fever. In some cases wmich we have seen, we had no doubt that 
they w^ere influenza and not scarlet fever — this conclusion being arrived at 
rather from the fact that influenza was epidemic and there were cases in 
the same household and neighbourhood, than from being able to decide 
from the symptoms and examination of the patient. Kramsytyk records an 
epidemic of influenza in Warsaw, accompanied by a red rash : on the other 
hand, Filippow records sixteen cases in which influenza was complicated by 
scarlet fever. There may be an attack of the simple febrile type, already 
described as affecting younger children. A persistent, irritating cough, 
almost like whooping cough, is not infrequent. 



Epidemic Influenza — Enteric Fever 293 

One of the most serious forms which the disease can take is that in which 
vomiting is a prominent symptom. In some of these cases he fever is high, 
perhaps 104 or 105 F., there may be delirium or an excited state of the nervous 
system, the conjunctivae are injected, and the child restless and sleepless. 
Such a case will often suggest an acute meningitis. The vomiting is often 
continuous, and gradually exhaustion comes on. In one fatal case of this 
character which we saw the temperature was not high, not exceeding 102 F., 
and this for a time made the diagnosis of influenza doubtful. In the worst 
cases the vomiting continues unrelieved, and the child dies of exhaustion or 
in a convulsion. At the post-mortem no gross lesion is found, but there is 
usually venous congestion and marked injection of the venous capillaries. 
Another serious complication is pneumonia ; this may be either of the 
croupous or broncho-pneumonic type. The course is often protracted, and 
the mortality is higher than in the ordinary forms of pneumonia. Empyema 
is not an uncommon result. Less commonly there is a catarrh of the small 
or large bowel, giving rise to troublesome diarrhoea and colic. We have 
seen several cases of acute ileo-colitis which occurred during an epidemic of 
influenza, but we could not for certain say they were due to this cause. We 
have seen cases that certainly resembled enteric fever. Meningitis has been 
described as occurring in some attacks (G. W. Earle). Severe otitis is not 
uncommon. Relapses are common, and the possibility of their occurrence 
will always have to be borne in mind. We have known death to take place 
in a relapse. As a rule, the depression which so commonly follows an attack 
of influenza in an adult is much less marked in the case of children. 

Sequela. — Chronic otitis is apt to be left by influenza. Various nervous 
sequelae may occur, more especially in adults. We have seen cases in which 
an irregular and intermittent action of the heart was left by attacks of influenza 
in children. Recovery seems always to take place. 

Treatmejtt. — The patient should be isolated, and confined to bed in a 
well-warmed room. As long as the fever lasts his diet should consist of 
fluids, such as beef tea and warm milk. As a routine method of treatment 
we generally prescribe a mixture containing salicylate of soda, antipyrin, and 
spirits of chloroform (F. 50, 51). If the fever is high, vigorous antipyretic 
measures may be required ; to this end warm or tepid baths, with doses of 
phenacetin, antipyrin, or antifebrin, may be given. Other symptoms must 
be treated as they arise. The most difficult cases to treat are those in which 
the vomiting is a constant symptom. In these cases antipyrin in an effer- 
vescing mixture, iced champagne, and small quantities of raw beef juice may 
be tried. In the continued fever quinine may be given. 

Enteric Fever 

As a general rule it may be said that children and young people are 
more susceptible to enteric fever than are adults, and they usually suffer 
from ii in a milder and less complicated form. It is not common in children 
under three years of age, though it undoubtedly does occur even in infants, 
and may be fatal ; it is not easy to say at what period of life it is most 
common, as statistics of fever hospitals are apt to be fallacious, since the 
milder cases are certain to be nursed at home, and children suffering from 



294 The Specific Fevers 

the disease in a mild form will in a great many cases never enter a hospital 
at all. According to Collie, ten years to twenty years of age is the commonest 
time for an attack ; five years to ten years of age ranking next. The mortality 
at all ages from enteric fever, according to Murchison, is i 5 to 20 per cent. 
In children, according to Barthez and Rilliet and Gerhardt, 10 per cent. In 
our own hospital 592 cases have been treated, with 48 deaths, giving a 
mortality of 8 per cent. It is obvious that too much reliance must not be 
placed upon these figures, as in the different hospitals a different proportion 
of severe cases maybe admitted, or the mild and abortive cases mayor may 
not be reckoned as attacks. 

Enteric fever spreads by direct contact with the sick, by means of 
emanations from both fresh and stale faeces, possibly also by the breath, by 
inhalations of sewer gas given off from drains into which the excretions of 
enteric patients have been thrown, and by the taking of drink or food which 
has become contaminated by the specific bacilli. There is reason to believe 
that infection may be carried from the sick to the healthy on the fingers or 
clothes of a third person. The evidence that enteric fever is directly con- 
tagious, the disease being contracted by coming in contact with a patient, is 
too strong to be explained away — notably the evidence produced by Collie 
at the Homerton Fever Hospital ; and in our own hospital hardly a year 
passes without one or more probationer nurses contracting the fever from 
patients they are nursing ; and we have known it to happen that patients in 
the same ward with cases of enteric fever, who have never been out of bed, 
have contracted the fever, doubtless by the bacillus having been brought to 
them by one of the attendants. It appears to spread in this way in the 
crowded homes of the poor, where one member, mostly one of the children, 
contracts the disease, and remains at home, being nursed in a room where 
others sleep ; then in the course of two or three weeks other members are 
attacked. Indeed no disease is more certain to spread in the crowded 
dwellings of the poor than enteric fever. 

Incubation. — Usually fourteen to twenty-one days. 

Symptoms and Course. — In every epidemic cases maybe met with which 
are so mild that they can only be recognised as enteric as they occur in 
the same house with other undoubted cases. In such cases the temperature 
may be from first to last intermittent, being perhaps 102 or 103 in the 
evening, and falling nearly to normal the following morning ; evidently these 
cases were included by the older writers under the term ' infantile remittent 
fever.' Other cases, which begin like an ordinary attack, abort by the end 
of the second week, and are at once convalescent without going through the 
ordinary three weeks' course. In other cases the morning remission is much 
more marked, being perhaps three or four degrees lower than the evening, 
and this tendency is especially shown after the middle of the second week. 
In these mild cases the patient does not appear ill ; in the morning the child 
will be seen sitting up in bed playing with his toys ; and but for a heavy look 
about the eyes and a glance at the temperature chart over the bed, it would 
be difficult to persuade oneself that he was suffering from any febrile disease. 
Such patients are often brought to the out-patient rooms of dispensaries, and 
are not considered by their parents as anything but 'out of sorts.' There is 
rarely diarrhoea in the milder cases. On the other hand, cases of great 



Enteric Fever 



295 



severity may be met with in children, the fever may run high and last for 
many weeks, or fatal complications may supervene, or death may take place 
early in the disease from the intensity of the poison, as in the case of a child 
of three years coming under our notice who died as early as the eighth day. 
Initial Symptoms. — These mostly come on gradually, though exceptionally 
there is a somewhat sudden onset ; the fact that the onset in any case has 
been abrupt does not certainly negative the diagnosis of typhoid fever. 
Frontal headache is nearly always complained of, with a feeling of chilli- 
ness which induces the patient to sit over the fire ; there is usually ' rambling ; 
at night, less often abdominal pain, diarrhoea, and epistaxis. 




Fig. 55-— Temperature Chart of a case of Mild Enteric Fever in a boy aged 9 years. 



Temperature. — In an attack of ordinary severity the evening temperature 
reaches 104 by the fourth evening, continuing to reach this point or there- 
abouts once daily for about ten days, the diurnal remissions usually being 
i° to 2° ; the remissions then become more marked, amounting to 2° or 3 , the 
fever gradually subsiding by lysis, and of an intermittent type, remaining 
normal after the twenty-first day (see fig. 56), though perhaps touching normal 
a day or two before. The highest temperature of the twenty-four hours 
is usually late in the afternoon at 4 or 5 P.M. ; later in the attack it is post- 
poned, and reaches its highest point at 8 P.M. or midnight. In mild 
attacks there is a marked tendency to remit 2° or 3 or more early in the 
attack, and to abort at the end of the second week, in a way which is rare in 
adults. 

Hyperpyrexia is the exception in children ; in a few cases a temperature of 



2g5 The Specific Fevers 

105 or even 106 may be reached, but the usual maximum temperature during 
twenty-four hours in the first ten days is 103 to 104°. 

The temperature curve of a relapse differs very much in different cases ; 
it is usually of a remittent type. It is hardly necessary to insist that the 
temperature should be always carefully taken during enteric fever, as it 
affords the best index we possess of the severity of the disease or the patient's 
progress to recovery. 

Tongue and Mouth. — During the first week there is usually nothing 
characteristic about the tongue ; it is coated with a thin white fur, butjis 
clean and moist at the edges ; there is often a glazed clean strip down the 
centre. It may remain moist and furred throughout, while later, especially 
in cases of moderate severity, the tongue is covered with a brown fur, dry, 
with a brownish glazed central strip. Later the tongue becomes clean, red 
and glazed ; sometimes there are superficial ulcerations on the surface. 
Sordes very readily collect on the teeth, and the mouth becomes foetid if 
not cleansed. 

Abdomen. — The abdomen does not become distended till the end of the 
first week ; during this time the distension gradually becomes more and 
more marked from the accumulation of gases in the small intestines; at 
the same time a certain amount of pain on deep pressure may be elicited 
and gurgling detected in the iliac fossae. By the end of the third week, if 
the temperature has become normal, the abdomen becomes less rounded, and 
gradually returns to the normal condition. In mild cases the abdomen may 
be normal from first to last. 

Spleen. — The spleen usually enlarges during the first week ; the earliest 
day on which we have felt it to be enlarged was in one case on the sixth day. 
It continues enlarged and somewhat soft during the pyrexia ; according to 
Jacobi, if the spleen remains enlarged after the temperature has fallen, a 
relapse is to be feared. In some cases there is no enlargement to be felt 
during life, and the post-mortem has revealed a spleen of normal size 

Bowels. — Typical ' pea-soup ' stools are the exception in children, certainly 
diarrhoea is not usually a prominent symptom. The bowels may be con- 
stipated or normal, they may be simply loose, or there may be the watery 
pea-soup stools characteristic of the disease. As a rule it is the severe cases 
which have troublesome diarrhoea, but cases may be severe with high tem- 
perature and prolonged course without diarrhoea being present. During con- 
valescence constipation is apt to be troublesome, on account of the atony of 
the bowel left by the disease. 

Cerebral Symptoms. — Slight delirium at night with a tendency to talk 
and chatter nonsense is common ; acute delirium like that present in typhus 
or acute pneumonia is rare. After a severe attack the mind sometimes 
remains weak, a condition of dementia existing for some weeks ; sometimes 
aphasia is left ; more often the loss of speech is due to mental weak- 
ness. The prognosis is good, the mind recovering as the system gathers 
strength. 

Eruption. — The characteristic rose spots are present in about 75 per cent. 
of the cases. The spots may be detected by the end of the first week, rarely 
earlier : fresh spots appear daily till towards the middle of the third week : 
they may go on longer, into the fourth or even fifth week. They often 



Enteric Fever 



29/ 



reappear during a relapse. Their numbers vary from two or three to many 
hundred, so that the child has a freckled appearance. 

Urine. — If the temperature is high and continuous, albumen in slight 
quantity is mostly present. Indican is often present. The urine is high- 
coloured and concentrated. 

Complications. — The same complications that occur in adults are found 
also in children. There is the same tendency to relapse, there may even 
be more than one. Not infrequently the relapse is more severe than the 
primary attack ; death from perforative peritonitis may take place in a 
relapse. The interpyrexial period is very variable. Thus in a severe case 
the temperature touched normal on the twenty-first day, was then inter- 
mittent till the thirtieth, then normal till the thirty-fourth, then a relapse 




Fig. 56. — Temperature Chart of a case of Enteric Fever in a girl aged 9 years. 
* rose spots ; f spleen felt. 

occurred, the temperature varying from 102 to 104 , till it reached norma 
again on the fifty-third day ; recovery followed. In another case the 
primary fever ended on the nineteenth day, a relapse occurred on the 
thirtieth, lasting till the fiftieth. In another the primary fever ended on 
the twentieth, the relapse occurred on the twenty-eighth, and lasted till 
the forty-second. In another the primary fever ceased on the twenty- 
fifth, and a relapse occurred lasting from the twenty-seventh to the forty- 
sixth. 

Epistaxis is not uncommon as an early symptom, and is of no import- 
ance. Small quantities of blood in the stools are common during the 
second and third week, and if small in quantity need not be a cause of 
alarm. Smart haemorrhage from the bowels is rare, though serious when 



298 The Specific Fevers 

large in amount, yet we have not seen a fatal case result from it in a child. 
We have seen severe haemorrhage in three cases, all, however, ending 
in recovery. In one case, a girl of eleven years, there was a fall of tempera- 
ture on the twenty-seventh day, from 103-2° to 98-8°, followed by a 
haemorrhage of 10 oz. of blood per rectum ; another haemorrhage occurred 
on the thirty-first day, and again on the thirty-second clay some 12 oz. 
were passed ; she eventually recovered. In another case, in a boy of 
twelve years, who was admitted after having been ill a month, the same 
evening there was a large haemorrhage per rectum, sufficient to blanch 
his lips, and for the time he was nearly pulseless ; he finally recovered. 

Bronchitis and pneumonia come on in many of the severe cases ; they 
occur quite independently of a chill or from taking cold ; they are due 
rather to stasis of blood in the lungs, mostly at the bases, and possibly also 
to the local working of the specific bacillus of enteric fever. Diminished 
resonance with rales and rhonchi are detected at one or both bases if 
pneumonia is present. The temperature is usually high, and the pulse and 
respiration are increased. We have seen death take place from this cause 
on the nineteenth, twentieth, twenty-first, twenty-third, and thirty-fifth days. 
The pneumonic lung is of a purplish colour, has a solid airless feel, and is 
often more or less collapsed on section ; the cut surface is not granular like 
croupous pneumonia, but smooth and dark red. The lung is airless and 
sinks in water. 

Pyaemia, with secondary abscesses in the lungs and elsewhere, the result 
of septic embolism from the ulcers in the intestines, occasionally occurs. In 
four of such cases dying in the Children's Hospital, the course of the disease 
was acute, with hyperpyrexia and an intermittent temperature towards the 
close ; one died on the nineteenth day with suppuration in the parotid, the 
others on the twenty-fifth, -twenty-ninth, and thirty-seventh days respectively. 
At the post-mortem pyaemic abscesses due to infarcts, and pneumonia were 
found. 

The most dreaded complication in enteric fever is perforation of the 
intestine followed by peritonitis, in consequence of an ulcer penetrating 
through the wall of the intestine. This complication is fatal with very few 
exceptions, though it is difficult to say if it always is, as cases with 
symptoms of peritonitis sometimes recover, and it is not unreasonable to 
suppose that at times no extravasation may take place, the affected portion 
having become glued by means of lymph to another piece of intestine. In 
four of our cases death occurred on the sixteenth, twenty-second, thirtieth, 
and forty-eighth days respectively. In the case in which death occurred on 
the sixteenth day, it was not certain if it was the sixteenth day of the primary 
fever or of a relapse, as there was a history of indefinite illness before ad- 
mission. The temperature on admission was normal, though there was some 
rhonchus and rales were heard in the chest ; the disease ran an acute course 
(fig. 57) for fifteen days, when suddenly there was collapse, the temperature 
falling abruptly, with vomiting and abdominal pain ; the temperature rose 
again to 104°, death occurring next day. A perforation in the ileum, three 
inches from the caecum, was found, with extra vasated faeces and general 
peritonitis. In all the cases there was abdominal pain and collapse a clay or 
two before death. In the case in which death occurred on the forty-eighth 



Enteric Fever 



299 



day, the girl had been ill three weeks before admission, and the attack 
treated in the hospital may have been a relapse. There was hyperpyrexia 
and intermittent fever. 

Some cases of enteric begin with tonsillitis and membranous exudation 

on the tonsils ; occasionally sloughing tonsillitis supervenes in the course of 
the attack ; this was so in one fatal case, in another a membranous laryngitis 
occurred causing death on the twenty-first day. Otitis may occur, and 
occasionally a fatal result follows from thrombosis of the lateral sinus and 
pyaemia. 



SBflBSflEflSBESSSfiflEB! 




iiiill Hi IHIi 



mm m 
m ra 





iiiii 



fiiliiliilililiili 

■RNUiniMKiniifli 



iiliiiiiiiiiiliiili 



m annniV'BiBiBt'.H 
iiifiiiiMiauw 

i*i5! SHSSSaSS 

■si ill III 




ilyiiiilliiiiliiliiiiiilliiliiiii 
llll lllllll llllllilillllilllllli 



Fig- 57. — Temperature Chart of Enteric Fever ; Peritonitis ; death sixteenth day 
in a girl of 9 years. 



Tuberculosis may complicate the course of enteric fever, or it may 
follow as a sequela. In one case a child died of pneumonia on the twenty- 
first day ; tubercles were present on the pleura and in the lung. In another 
case a girl recovered from enteric, the temperature becoming normal on the 
twenty- sixth day ; it remained normal for a few days ; she continued to im- 
prove for a month, though the temperature went up occasionally at night. 
Then hectic fever came on, with vomiting, and she died comatose three weeks 
after ; the post-mortem showed tubercular meningitis and a few tubercles in 
the rimers. 



30G The Specific Fevers 

Diagnosis. During the first few days the diagnosis of enteric is difficult, 
often impossible, and especially in children typhoid may be confounded with 
the feverishness which so often accompanies dyspepsia and intestinal catarrh. 
Children are frequently brought to the out-patients' rooms of children's 
hospitals with indefinite symptoms and feverishness ; a tentative diagnosis 
of enteric is made, but in a few days the symptoms disappear and the child 
is practically well again. Such attacks may be more severe, and it may be 
impossible to say whether the patient has had an abortive enteric attack or 
not, unless there are undoubted enteric cases in the household. In all doubt- 
ful cases, in the early stages, the temperature should be carefully taken every 
four hours and a careful examination made for rose spots and enlargement 
of the spleen. The diagnosis in small children and infants is extremely 
difficult, on account of the many causes, such as patchy catarrhal pneumonia, 
intestinal catarrh, influenza, and tuberculosis, which may give rise to an inter- 
mittent or remittent fever ; it must have occurred to almost every medical 
man in practice to have seen babies or young children with an intermittent 
fever lasting two or three weeks or more, with flatulent abdomen, but no 
distinct enlargement of the spleen, rose spots, or diarrhoea. Perhaps there 
are no cases of enteric in the neighbourhood. Here diagnosis maybe im- 
possible. We have never seen a fatal case of typhoid in an infant under two 
years of age, but such cases have been recorded. It is possible that some of 
these continued febrile attacks are due to some other form of bacillus. The 
bacillus coli communis has been suggested by some French authors ; they 
believe it may take on a malignant action. Widal's serum reaction though 
not apparently absolutely reliable is a very valuable means of diagnosis. 

Acute Miliary Tuberculosis and enteric may be very similar, and for 
a week or two the diagnosis may have to be held in abeyance. Careful 
temperature-taking every four hours will often greatly aid the diagnosis. In 
acute tuberculosis the fever is mostly intermittent, the diurnal ranges being 
perhaps 3 to 5 ; there are no true spots, rarely diarrhoea ; miliary tubercles 
may occasionally be detected in the choroid, crepitation may be heard in the 
lungs, or there may be some want of resonance at one apex ; the abdomen 
is not usually rounded. Tubercular Meningitis in the early stages may 
simulate enteric. A child who is seen for the first time, recovering from 
typhoid fever, being anaemic, wasted, and having perhaps some cough with 
rhonchi heard on examining the chest and possibly bedsores, might readily 
be thought to be suffering from Chronic Tuberculosis. If there is diarrhoea 
and abdominal tenderness, the two diseases at this stage may be still more 
alike. A careful examination of the lungs would generally distinguish 
between the two, as in chronic tuberculosis some consolidation at the apices or 
elsewhere would usually be found. Pyaemia may resemble enteric fever, 
especially in those cases where the pyaemia is secondary to some bone 
disease without any external wound. A case of pyaemia secondary to Pott's 
disease of the spine, with abscesses in the lungs, which came under our care 
was thought for a few days to be enteric fever ; but the daily ranges of tem- 
perature are more extreme, the type more markedly intermittent in pyaemia 
than typhoid. A rounded distended abdomen, with a pimply rash, may cer- 
tainly occur in other diseases than enteric, though when true rose spots are 
present they are characteristic. 



Enteric Fever 301 

Morbid Anatomy. — The solitary glands and Peyer's patches are swollen 
in catarrh of the bowel, enteritis, also in scarlet fever and septicaemia, as well 
as in enteric fever. Ulceration occurs in the later stages of enteritis, ileo- 
colitis, and tuberculosis, as well as in typhoid. In a typical case of typhoid 
there is usually no difficulty in making a post-mortem diagnosis, as the 
swollen condition and ulceration of Peyer's patches, enlargement of the 
spleen and absence of tubercle are sufficiently characteristic. If death 
takes place early in the disease, there may be more difficulty. Eberth's 
typhoid bacillus is with difficulty distinguished from other bacilli in the 
faeces ; but if present in spleen pulp or juice, then its diagnostic value is much 
greater. 

Treatment. — The management rather than the medicinal treatment of 
typhoid fever is of the greatest importance. The patient must of course be 
put to bed in a cool room, and arrangements made for both night and day 
nursing ; it is needless to emphasise the importance of a trustworthy nurse 
at night to feed and attend to the patient's wants and soothe him to sleep. 
Sponging with warm water, to which some Condy's Fluid or Sanitas has been 
added, should be performed every evening before settling the patient for the 
night, great care being taken to cleanse the buttocks and anal region, 
especially if the patient is suffering from diarrhoea, as the stools are apt to 
be smeared about. To keep the patient's back scrupulously clean is a matter 
of importance in the prevention of bedsores. The patient's mouth must be 
carefully attended to, and cleansed by means of a paint brush or rag of 
decomposing food and foul secretions ; the more ill and insensible the 
patient is, the more important does this become. Condy's Fluid or dilute 
solution of boro-glyceride may be used for the purpose. The diet should 
consist of milk diluted with barley water or soda water, and in amount should 
be suited to the age. During the pyrexial period milk is better taken than 
beef tea or other savoury foods, which as a matter of fact are quite unneces- 
sary. The more thirsty the patient is, the more must his milk be diluted, 
lest too much curd remain undigested in the stomach and intestines, and give 
rise to flatulence and discomfort ; a pint and a half to a quart of milk daily 
will be sufficient. An excess may give rise to diarrhoea or accumulate in the 
large intestine as hardened faeces. In the later stages, when the tongue is 
cleaning, beef tea is usually taken well, and forms a pleasant change of diet. 
Where milk does not agree, or when the diarrhoea is troublesome, peptonised 
milk or Benger's Food should be given. It is well to continue the fluid diet till 
a full week after the temperature has become normal. Our usual practice is 
to allow sops in the milk or beef tea on the thirtieth day, at once discontinu- 
ing it if the temperature rises. In mild or medium cases alcohol is unneces- 
sary. No medicine is required ; a simple saline may be given. The treat- 
ment of hyperpyrexia must depend upon the effect which it has upon the 
patient, though in any case, if the temperature rises to 104 , sponging the 
head, trunk, and limbs with water at 6o° should be resorted to, or the cold 
pack may be given, provided there is no immediate risk of peritonitis. If the 
temperature is not kept in check by these means, but the fever is not making 
the patient drowsy or delirious, no other means need be taken, except perhaps 
applying an icebag to the head. Other means are however available, such as 
the administration of phenacetin or quinine, and the graduated bath. Anti- 



302 The Specific Ferns 

febrin and antipyrin arc best avoided, as too depressing. In the early stages, 

with due care, the graduated bath is useful in reducing temperature ; in the 
later stages it is contra-indicated on account of the disturbance to the patient 
which it entails. The patient may be placed in the bath at a temperature of 
ioo°, and cold water added so as to reduce it to jo° or 8o°, though it is rarely 
wise to allow the child to remain in longer than five minutes. Excessive 
diarrhoea should be checked by starch and opium enemata, or Dover's powder 
by the mouth ; sleeplessness and delirium by a wet pack or small doses of 
nepenthe, the latter being more useful than bromides, chloral, or urethan ; 
abdominal pain or tenderness is best treated by nepenthe in free doses by the 
mouth, and opium fomentations, while the food and liquids taken are reduced 
to a minimum compatible with safety, pneumonia by stimulating applications 
such as mustard poultices or turpentine stupe, the latter being used with great 
care on account of the sores apt to be produced. Any signs of cardiac 
depression must be combated by alcohol in the form of mist, vini gallici, or 
champagne, or by caffeine, ammonia, ether, or digitalis. 

It is often an anxious question to decide as to whether a laxative should 
be given when the bowels are constipated, inasmuch as a patient is rendered 
more comfortable by a free action of the bowels, and the distension and dis- 
comfort are lessened. On the other hand, one fears that the peristalsis set up 
by a purgative or even an enema may do irretrievable damage by converting 
an ulcer into a perforation or tearing down adhesions of lymph which have 
formed. At the same time it must be remembered that hard lumps of faeces 
irritate the bowel and fret and rub the ulcers, and in some of the worst instances 
of extensive ulcers in fatal cases we have found numerous hard lumps of 
faeces in the lower part of the ileum and large bowel. Some doses of castor 
oil during the first ten days are often beneficial if the bowels are confined ; 
after this time enemata are safer, though they are not free from risk, and should 
certainly be avoided if there are signs of peritonitis. If severe haemorrhage 
from the bowel occur, the greatest care must be taken to give the child only 
the smallest quantities of food by the mouth and to keep him as quiet as 
possible. An ice bag should be placed on the abdomen and a grain of ergotin 
given subcutaneously and repeated every two or three hours. Opium should 
be given in small doses if there is much restlessness. Turpentine or terebene 
in two or three drop doses in mucilage is useful as a stimulant and haemo- 
static. 

Can we abort enteric fever by giving laxatives or antiseptics ? This is a 
disputed point, inasmuch as enteric frequently aborts, especially in children, 
without the help of drugs, and the diagnosis in the early stage is difficult. 
We certainly believe that the danger of setting up perforation-peritonitis by 
giving purgatives has rather frightened us unnecessarily into the too sparing 
use of evacuant remedies such as calomel or castor oil. Small and repeated 
doses of calomel or castor oil during the first ten days may be safely given, 
and in many cases with great benefit. We are less inclined to the heroic 
doses of calomel advocated by some physicians. 

During convalescence dyspepsia and constipation are frequently trouble- 
some ; flatulence and a rise of temperature are very apt to follow any excess 
of starchy or any indigestible food, especially in early convalescence. The 
food should consist of meat essences, of broths, jellies, pounded meat, 



Enteric Fever — Typhus 303. 

chicken, and fish, with small quantities of toast or stale bread. Good sherry 
with a grain or two of pepsine and some liquid malt extract are often very 
useful. The constipation is usually slow in disappearing ; purgatives should 
be avoided, as the constipation is simply due to wasting of the muscular 
fibre of the bowel and weakened secretions. In this condition the mineral 
acids, strychnine, cascara sagrada and bitters are of most use. 

Typhus 

During an epidemic of typhus children suffer equally with adults, though 
the mortality is exceedingly small. It is probable that the fact that children 
usually suffer from the disease in a mild form, and but few die, has given 
rise to the general belief that children are less susceptible to the typhus, 
poison than are adults. That this is not the case has been shown con- 
clusively by Dr. Buchanan, who, after referring to the slightness of the fever 
in children, says : ' When inquiry as to age is made to include every case of 
attack, children and adults are found to be equally susceptible ; the actual 
incidence may even be observed to be strongly upon the young, partly 
because of their greater numbers and partly because adults are frequently 
protected by previous attacks.' That many children are attacked with 
typhus is shown by the statistics of Homerton Fever Hospital (given by 
Collie), for out of 711 admissions of typhus to the hospital during the period 
1871-1880, 24 were under 5 years of age, 54 from 5 to 9 years, 113 were 
from 10 to 14 years of age ; it is more than probable that the proportion 
really attacked as compared with adults was much greater, but on account of 
the mildness of the fever they were nursed at home and not sent to hospital. 
Only two deaths took place among the 191 children under 14 years of age ad- 
mitted, while the total mortality was ten times greater, being nearly 20 per cent.. 

Symptoms and Course. — The symptoms and course do not differ from 
those seen in adults, with the exception of their usually greater mildness.. 
The attack commences with headache, pains in the limbs, drowsiness, more 
or less shivering, sometimes vomiting, rarely diarrhoea. This history closely 
resembles that often obtained in scarlet fever, and this should be borne in 
mind, as a hasty conclusion as to the nature of an attack may be a wrong- 
one. If seen for the first time at the end of three or four days, there is a 
listless expression on the face ; it is flushed, the eyes suffused, the conjunctivae 
injected ; the child may answer questions if spoken to sharply, but is drowsy, 
semi-delirious and irritable if interfered with. The tongue is dry, coated 
with a brown fur and protruded with difficulty, the lips are black, there 
are sordes on the teeth, while the gums easily bleed. An examination of the 
lungs reveals the presence of rhonchi, perhaps rales, and some loss of re- 
sonance at one or both bases. On the fourth or fifth day the rash usually 
appears ; the skin has a dusky congested appearance, with an indistinct 
mottling, in addition perhaps to petechial points, due to flea bites ; for our 
patients with typhus usually come from the dirtiest and most squalid quarters. 
Perhaps a dusky mottling is all that can be seen, but in more typical 
cases the rash is more definite, consisting of rose-coloured spots, or macular, 
larger than typhoid spots, and with more ill-defined margins, scattered over 
the body. According to Collie they are first seen on the sub-clavicular 



304 



The Specific Fevers 



regions, along the lower border of the pectoralis major, on the wrists, back of 

the hands and epigastrium. We have sometimes noted the rash especially 
well marked on the dependent parts of the body, sides of the thighs, and 
arms, and back, extending along the neck on to the cheeks, and present also 
on the dorsum of the feet. The temperature is usually continuously high. 
103 to 104 , the pulse small and weak, perhaps 120 to 130, and there is some 
cough, and frequently much delirium or wandering at night. The fever may 
last for the whole two weeks ; more frequently the symptoms undergo marked 
amelioration after the first week, and possibly the temperature declines to 




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Fig. 58. — Temperature Chart of Typhus Fever, ending in recovery. Eliz. G., aged 7 years. 

normal by the eighth or tenth day, all the symptoms becoming milder and the 
rash disappearing without becoming petechial, as it often does in adults. 
The rash may be only visible for a few days or may fade as the fever becomes 
less. While the above description applies to a typical case in a child, very 
severe cases may sometimes be met with, though far oftener the symptoms are 
■decidedly milder. The tongue may never be brown, only coated with a white 
fur ; the rash may consist of a dusky mottling only ; there maybe drowsiness 
without active delirium. The late Dr. Tomkins observed in some of his 
cases at Monsall Fever Hospital that there was marked torpor and lethargy 



Typhus 305 

during the first few days, so that the child was with difficulty aroused to 
take food. 

It is obviously important to recognise typhus, though the attack may be 
mild, as such cases are of course infectious and may spread the disease. 
Dr. Tomkins recorded the case of a woman who contracted a fatal attack 
by sleeping with a child suffering from mild typhus ; the cause of the 
child's illness not having been recognised. 

Diagnosis.— The fact that typhus occurs in epidemics and is apt to prevail 
in the overcrowded and poverty-stricken quarters of a large city often helps 
the diagnosis ; but occasionally an epidemic breaks out in a school or in the 
homes of the well-to-do. The onset of the attack may suggest scarlet fever ; 
the high fever, drowsiness, and dusky condition of skin present in a malig- 
nant case of the latter disease might render the diagnosis doubtful at first ; 
but the condition of the tonsils would usually clear up a doubt if the 
characteristic rash of scarlet fever was not present. Nevertheless we have 
seen a case fatal in two or three days that gave rise to some doubt, and in 
the absence of a post-mortem was never cleared up. The disease most likely 
to be mistaken for typhus is acute pneumonia (Collie) ; this is in accord with 
our own experience, as we have seen cases of acute ' cerebral pneumonia,' 
with physical signs delayed, sent into hospital as typhus ; the mistake is 
likely to occur, as in most cases of typhus some rales or rhonchi are to be 
heard. 

In 'cerebral pneumonia' the lesion is often at the apex of the lung ; if 
seen on or after the fourth day of illness, and there is bronchial breathing 
or dulness, or some high-pitched resonance over a portion of lung and no 
rash, the disease is almost certainly acute pneumonia. A dusky or mottled 
skin, brown dry tongue, rales or rhonchi scattered over the whole lungs or 
bases, would indicate typhus. Enteric fever may be mistaken for typhus, 
especially when acute, but the insidious nature of the onset, the absence 
of marked delirium or torpor, the tenderness on pressure over the abdomen, 
and the rose spots usually suffice to make a diagnosis. We have seen some 
cases of typhus where there w r as a good deal of general hyperesthesia and 
muscular tenderness, where pressure on the abdomen evoked expressions of 
pain. 

Prognosis. — This is mostly good, but fatal cases sometimes occur, the 
children succumbing in the first few days of the fever from the intensity of 
the poison. 

Treatment. — That of fever generally. Sponging with Condy s Fluid should 
be resorted to daily ; the apartment should be large, airy, and warm ; stimu- 
lants are required in all but the mild cases ; milk and other liquid nourish- 
ment must be given in suitable quantities. Directly convalescence has set 
in a more liberal diet may be allowed. 

Varicella 

Varicella is a specific infectious disease closely resembling modified 
smallpox, though perfectly distinct from it. There are still a few who 
believe varicella to be a variety of smallpox, notwithstanding the many 
facts which point in a contrary direction ; these may be summed up as 

x 



3o6 



The Specific Fevers 



follows : the two diseases are not mutually protective— children who have 
recently had smallpox may contract varicella ; during epidemics of one 
disease the other is not usually prevalent ; smallpox affects all ages, vari- 
cella affects children almost entirely ; inoculation with the virus of smallpox 
produces smallpox, inoculation with the contents of the vesicles of varicella, 
when successful, produces only chicken-pox. 

Varicella occurs in epidemics in schools, workhouses, children's hospitals, 
and among the poorer classes of society where there are many children in 
constant contact with one another ; its epidemics, however, are not so wide- 
spread as those of measles or whooping cough, nor does it affect so large a 
proportion of the unprotected. It affects children almost entirely ; thus in 
584 cases observed by Baader in Bale, 98 per cent, were under the age of 




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Fig. 59. — Temperature Charts of two cases of Chicken-pox in children of 
3^ years and 18 monrhs. 



ten years, and 65 per cent, below five years of age. Adults do, however, 
occasionally take it. We have several times seen nurses contract the disease 
from children suffering from it. 

Varicella can be communicated from the sick to the healthy by inocula- 
tion, by simple contact, or by infection being carried by a third person. 
Trousseau failed in his attempt to inoculate ; Steiner seems to have been 
more successful, succeeding in eight cases out of ten. The disease is most 
usually communicated directly from children suffering from or convalescent 
from an attack ; it is also certain that the infection can be carried by means 
of a third person, and remain in an active condition in clothes for many 
weeks, inasmuch as sporadic cases of the disease will occur in hospital wards 
in patients who have been in for months, and where no cases had occurred 
previously in the ward for a long interval. 



Varicella 



307 



Symptoms.— The incubation period in the inoculated cases reported by 
Steiner was eight days ; when contracted in the ordinary way it is usually 
about fourteen days, sometimes a day or two more. We have on several 
occasions had an opportunity of verifying this. There are usually no pre •- 
monitory symptoms ; the discovery of papules and vesicles on the body is 
usually the first thing noted by the friends. In a few cases there is a diffuse 
redness of the body resembling the roseolous rash which sometimes precedes 
smallpox, and which has given rise to the suspicion that the case is one of 
scarlet fever ; in one case a measly rash, preceding the vesicular eruption, 
made it look as if the child was suffering from both measles and varicella, 
but of this there was no confirmatory evidence. Frequent micturition was 
observed in one of our cases before ^__^ 

the rash appeared. The premonitory 
fever if present is of short duration, 
varying from a few hours to twenty- 
four hours, and in this respect varicella 
presents a marked contrast to variola. 
The temperature is not as a rule cha- 
racteristic, and varies with the acute- 
ness of the attack, mild cases with 
only a few vesicles being feverless, 
severe cases with a great number of 
vesicles being accompanied by a 
temperature of 104 or more. The 
most frequent type is the intermittent 

(fig- 59)- 

The rise of temperature is accom- 
panied by an accelerated pulse, coated 
tongue, and restlessness, though in 
mild cases these may be absent ; in 
a few hours rose spots, resembling the 
rash of typhoid, appear and quickly 
become vesicular. Probably at the 
time the first examination is made there 
will be both rose papules and minute 
blebs or vesicles containing clear fluid 
and surrounded by a zone of red- 
ness. By the next day a fresh crop of 
papules and vesicles will have appeared, the vesicles of the previous day are 
larger, perhaps some of them have aborted and commenced to dry up. 
Fresh crops appear on the third, fourth, fifth days, and perhaps later still, so 
that when the attack is at its height, as it usually is on the third or fourth 
day, the trunk and extremities are thickly covered with vesicles and scabs, 
probably also a few pustules where there has been some scratching and the 
vesicles have burst. The contents of the vesicles are at first quite clear ; as 
they enlarge their contents become more cloudy, but not purulent unless 
the vesicle has been injured and part of its contents has escaped. The 
vesicles are mostly unilocular, their upper surface is convex and collapses as 
soon as it is pricked, though in some cases a few vesicles may be seen more 

x 2 




Fig. 60. — Varicella Gangrenosa. Child aged 
2 years. From a photograph taken after 
death. The patient died of tuberculosis ; 
she had had an attack of Varicella two 
months before death. 



308 The Specific Fevers 

or less flattened, umbilicated, and multilocular, closely resembling smallpox 
or vaccination vesicles. The number of vesicles varies greatly ; in some 
cases only a few are present, in others there may be many hundreds. They 
are never confluent. In the majority of cases the vesicles dry up and scabs 
are formed at their site ; these fall off in the course of a few days, leaving 
clear and healthy skin beneath. In some of the worse cases this is not so ; 
an ulcer, which may be some weeks in healing, forms beneath the scab and 
thus a scar is left not unlike those following severe smallpox. The vesicles 
make their appearance on the trunk, limbs, and scalp ; they are generally 
more sparely present on the face, tongue, and soft palate. 

The prognosis in varicella is uniformly good, as it is apparently never 
fatal in a previously healthy child. In weakly and tubercular children the 
varicella vesicles are apt to be followed by spreading ulcers, which, joining 
one another and taking on an unhealthy action, sometimes assist in bringing 
about a fatal result. Such cases have been described by Mr. Hutchinson 
under the name of varicella gangrenosa ; they are not uncommon in the 
out-patient room (see fig. 60). The gangrenous action is usually associated 
with tuberculosis, and it is curious that in all fatal cases of this affection — as 
has been remarked by Dr. J. F. Payne — tubercle has been foundpost mortem. 
Eustace Smith has known acute tuberculosis to follow varicella, and we have 
also seen several such cases. Nephritis is an occasional sequela, as first 
noted by Henoch. 

Diagnosis. — The disease with which chicken-pox is most likely to be 
confounded is mild or modified smallpox, but as a rule no difficulty is ex- 
perienced. The points of most importance in making a diagnosis are the 
absence of premonitory symptoms and the character of the rash ; the following 
table shows these : 

Varicella Varioloid, or modified Smallpox 

Incubation. — Thirteen to sixteen days. Twelve days. 

Premonitory Fever. — A few hours. Two or three days. 

Premonitory Symptoms. — Mostly nil. May include headache, backache, drowsi- 

ness, vomiting, delirium, convulsions. 
Rash. — Red spots becoming vesicular in a Red shot-like papules appearing on face, 
few hours and drying up in three or four wrists, body, limbs, and soft palate ; in 

days, leaving crusts ; coming out in crops the course of a day or two the papules 

on four or five successive days on the becoming vesicles, and developing into 

scalp, trunk, limbs, face, and mucous pustules by the eighth day, or they may 

membranes. The vesicles are mostly dry up leaving only scabs, 

unilocular. 
Temperature. — Intermittent in character. Sudden rise, reaches its height when the 

papules are fully out ; then comes a 
speedy fall. The secondary fever is 
slight or absent in modified cases. 

Occasionally a vesicular syphilitic eruption may simulate varicella, though 
such eruptions are rare in congenital syphilis, and when present take the form 
of bullae of various size rather than vesicles. In one case which came under 
our notice, a vesicular syphilide closely resembled varicella, but there was no 
fever, and some brown staining followed the rash. 

Quarantine. — How long does the infection last in varicella ? No case 
should be considered past the infection stage until all the scabs have cleared 



Varicella — Vaccinia 309 

away and the skin is quite smooth and normal. This is usually accomplished 
in three or four weeks. In one case which was admitted to hospital 
suffering from psoriasis, which had succeeded the eruption of chicken-pox, 
and where some unhealed ulcers were present, the admission into the ward 
was followed by an outbreak of the disease some fortnight afterwards. The 
child admitted had had chicken-pox five weeks before. 

Treatment. — Not much treatment is necessary. The child should be 
isolated, and preferably be kept in bed if there is a copious eruption. A 
light diet should be given, and ointment containing some tarry or carbolic 
compound will be useful to apply to the scabbing vesicles. 

Vaccinia. — Performance of Vaccination. — The safest age for vaccinating 
infants has been in dispute, some preferring to vaccinate within a few weeks 
of birth and before the monthly nurse leaves, while others much prefer post- 
poning the operation till three or even six months. Inasmuch as unvacci- 
nated children under one year if they contract smallpox almost certainly die, 
no time should be lost in vaccinating infants if there is any chance of their 
being exposed to contagion — as, for instance, if smallpox exists in the house 
or is present in the neighbourhood in epidemic form. On the other hand, if 
the risk of their being exposed to contagion is small, it is unwise to vaccinate 
during the first few weeks of life, on account of the disturbance of the general 
health liable to follow ; infants of three months or six months old bear the 
operation better than infants a few days or weeks old. We prefer the age of 
six months. It is of importance to postpone vaccination beyond the end of 
the third month if the infant is not robust, or suffers from diarrhoea, malnu- 
trition, eczema, intertrigo, or if erysipelas is prevailing in the neighbourhood. 
Revaccination should be performed at or before puberty. If human lymph 
cannot be obtained from an infant of an undoubtedly healthy family, 
glycerinated calf lymph should be obtained, and if the latter is used, any 
objection to the performance of vaccination on the ground of transmitting 
syphilis and other diseases is obviated. The cuticle should be removed by a 
few scratches of a needle or lancet at the spot where a drop of lymph has 
been applied. After vaccination nothing is usually to be seen till about the 
third day, when there is some itching and a slight redness surrounding the 
spot, or there may be a tiny papule. By the seventh or eighth day there is a 
flattened vesicle at the seat of puncture, containing clear fluid in various 
loculi. During the next few days a red areola forms round the vesicle and 
its contents become cloudy ; by the tenth or eleventh day the fluid oozes out 
and forms a scab on the surface, which, becoming detached, leaves a super- 
ficial ulcer, which takes a variable time to heal ; a permanent cicatrix, 
which is circular, depressed, pale, and pitted, is left. The size and distinctness 
of the scar will depend upon the ulceration which has followed the pustule ; 
if the latter dries up without an ulcer forming, there will be hardly any scar 
left. There is often some febrile disturbance from the fifth to the tenth day. 

What are we to regard as the best vesicles for obtaining lymph from ? 
According to Dr. Hugh Thompson, 1 ' they are such as, at the beginning of 
the eighth day (the day usually chosen for taking lymph, although not always 
the best), show the punctures made in vaccinating well healed with no 

1 ' Inoculation for Smallpox,' by Hugh Thompson, M.D. ; Glasgow Medical Journal, 
vol. xxvii. 



310 The Specific Fevers 

scabbing, the vesicles depressed in the centre and elevated at the margin, 
containing a moderate amount of lymph, not acuminated ; that is, flat in 
proportion to breadth, and not having lost the inequalities, bosses and foveae 
— resulting from some of the connections between the epidermis and corium 
still remaining intact, the areola incipient or only slightly developed. The 
lymph which exudes from them, on being pricked, is nearly if not quite 
limpid, somewhat viscid, moderate in quantity, and does not tend to run 
down the arm. 

' As a general rule it is the finest children — those, at least, who are such 
in the eyes of the vaccinator : " children of dark complexion, with a thick, 
clear, smooth skin," as Seaton remarks, indications of a strong vigorous 
constitution — who furnish the finest vesicles. At the same time care must 
be taken to see that the child is in perfect health, and especially, by a thorough 
examination, that it is free of all skin diseases, and more particularly all 
indications of syphilis, among the most persistent and obvious of which 
(excepting, of course, manifest syphilides) are chronic coryza, generally from 
birth ; a depressed nose, open fontanelles, hydrocephalic head, turgid veins 
of scalp, tumid lymphatic glands. Many of the manifestations of syphilis 
disappear under treatment, and it is possible they may have thus disappeared 
without the disease being thoroughly eradicated ; but it is rare that one or 
more of the above may not be found if searched for. It is superfluous to 
caution against the smallest admixture of blood.' 

Complications and Sequela. — These are fortunately few, though numerous 
and important in the eyes of prejudiced persons, and a lengthy list could be 
easily compiled if all the evidence collected by such were to hold good. The 
most important are the following : (i) Syphilis (see infra) ; (2) Erythema 
and Erysipelas. There may be an unusual amount of redness and hardness 
surrounding the pustules, as a result of the lymph causing more irritation 
than it commonly does ; this may spread down the arm, and give rise to some 
glandular enlargement without there being any erysipelas present. Ery- 
sipelas does occasionally occur. The erysipelas coccus may gain entrance 
into the wound at the time of vaccination ; in this case symptoms will pro- 
bably arise within a few days, the incubation period being a few hours to two 
or three days. It is impossible to say for certain that it may not be longer. 
In a case which came under our notice the seat of the vaccine punctures 
began to become inflamed nineteen or twenty hours after vaccination. In 
such cases the vesicles and pustules often mature earlier than in normal cases, 
and a vesicle may be present on the second day, with more or less redness 
around the punctures. The patches of redness and oedema are migratory, 
as in other forms of erysipelas — that is, they do not necessarily remain in 
the immediate neighbourhood of the wound, but may affect the face, trunk, 
or any other part. The mortality of vaccine erysipelas is very high, most 
of the cases being fatal, death occurring in one to three weeks. It has un- 
fortunately happened that the vaccine has been taken from an infant suffer- 
ing from or incubating erysipelas, and has communicated erysipelas to infants 
vaccinated with it. Erysipelas may supervene at any period between 
vaccination and the healing of the pustules if the infant is exposed to 
the infection, the cocci becoming accidentally implanted into the wound. 
(3) Glandular enlargement. The axillary and cervical glands may enlarge 



Vaccinia 3 1 1 

and suppurate during the maturation of the pustules, or more commonly in 
the second week. We have seen several cases in infants with chronically 
enlarged and caseating superficial cervical glands of the left side, which had 
commenced to enlarge shortly after vaccination, and it appears likely that 
in infants of a tubercular or 'strumous' tendency vaccination may be the 
predisposing cause. Similar chronic axillary adenitis is also occasionally seen 
produced by vaccination, just as by any other irritation. (4) Cold abscesses 
and boils may form in various parts of the body, as they will at times after 
all suppurations, especially in tubercular or 'strumous' children. (5) 
Various rashes occasionally make their appearance, mostly towards the end 
of the week, when the vesicle is maturing. A roseolous rash over the body 
and arms, which is fugitive, disappearing mostly in twenty-four hours ; a 
vesicular rash, consisting of a few pimples becoming vesicular ; a lichenous 
rash ; and patches of erythema may be sometimes present. We know of 
no evidence which directly connects eczema with vaccination ; it is very 
common during infancy in one form or another, and it is not surprising that 
vaccination often gets the credit of producing it. An impetig-o is not 
uncommon, having been produced by inoculation of the secretions from the 
pustules by means of the finger nails. 

Varioloid or Post-vaccinal Smallpox, — Unvaccinated children suffer 
from smallpox in as violent a form as do unprotected adults ; indeed, 
according to Collie, ' smallpox is very fatal in unvaccinated children under 
five years of age, more than half dying, and nearly all infants under one 
year.' 

Children who have been vaccinated in infancy and take smallpox usually 
suffer from it in a modified form ; there may be no rash at all, or more often 
the attack aborts and the vesicles dry up without passing through the pus- 
tular stage, the secondary fever being absent or only slight. Sometimes 
the attacks, according to Collie, are so slight that diagnosis is impossible, 
except from the fact that they occur after exposure to infection or in associa- 
tion with cases of undoubted smallpox. The premonitory symptoms may 
be present — headache, feverishness, backache — which disappear before the 
rash appears, the attack coming to an end without any papular eruption. It 
is much more common for the attack to abort immediately after the rash 
appears, secondary fever or pustulation being absent. The premonitory 
symptoms may be severe — -headache, backache, the temperature rising to 
103 or 104 On the third or fourth day, a copious eruption of papules 
appearing, perhaps being confluent on the face, to be followed by a sharp 
fall in the temperature of perhaps 4 or 5 . The papules become vesicular and 
dry up with but slight if any pustulation, and the child is convalescent at 
once. 

The temperature chart (fig. 61) was that ot a child aged ten years who 
was convalescent from scarlet fever, and who contracted smallpox while in 
the scarlet fever ward ; the only source of infection which could be traced 
was a visit of her mother twelve days before, the latter coming four miles 
from a district where smallpox was prevailing. There was marked head- 
ache but no pain in the back ; on the third day an erythematous rash was 
seen on the body, which suggested that her illness might be scarlet fever, 
though she had passed through a typical attack some weeks before ; on the 



3*2 The Specific Fevers 

afternoon of the same day a few tiny papules like the rose spots of typhoid 
were seen on the abdomen and arms, the headache was severe and the eyes 
suffused. The spleen was enlarged, being felt \\ inch below the ribs. On 
the fourth day the face, neck, trunk, and limbs were covered with well- 
defined papules, many confluent. The same evening the temperature fell 
from 104 to 97 . On the fifth day the eruption was copious, some of the 
papules were beginning to be vesicular ; the vesicles quickly began to dry 
up and scab, no true pustules appearing. The girl made a good recovery 
and was not permanently pitted. 

Diagnosis.— The fact that smallpox is at times a very mild disorder 
makes it important that it should not be overlooked, inasmuch as a mild case 




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Fig. 61. — Temperature Chart of a case of modified Smallpox in a girl aged 10 years. 
Papular rash on the third day, becoming vesicular on the fifth. 

as well as a more severe one may be the means of spreading the disease. 
Diagnosis is hardly possible in the absence of a papular eruption, or the 
purpuric spots of the malignant form. 

Treatment. — The treatment is that of fevers generally. 



Whooping- Cough 

Etiology, &*c.— Whooping cough is an infectious disease which is 
characterised by a catarrh of the air passages and a peculiar spasmodic 
cough. It prevails in epidemics which are both widespread and prolonged, 
though sporadic cases are generally present in large centres of population. 



Whooping Cough 313 

There is no disease which is more certainly infectious than whooping cough, 
in the sense that if those who are unprotected by a previous attack come in 
contact with those suffering from it they are almost certain to take it. If 
one member of a household is attacked, all the other members, both children 
and adults, who are unprotected, take the disease. If it enter a court or 
alley, it is tolerably certain that all the unprotected inhabitants will suffer. 
It is almost certain to spread in a similar way in a school or convalescent 
home. It is, however, a curious fact which we have often noticed, that 
whooping cough does not appear to spread to any great extent in hospital 
wards in which the children are in bed and the cubic space great (the same 
fact has been noticed by Dr. Sturges and Dr. Goodhart), and it would almost 
appear that close contact with the infected individual so as to inhale his 
breath was necessary to give the disease. It is impossible dogmatically to 
deny that the poison of whooping cough can be conveyed on the person or 
by clothes to a distance and so infect the healthy ; but it is certainly excep- 
tional ; the common way in which it spreads is by direct contact with the 
sick. A very short contact is all that appears to be necessary — such, for in- 
stance, as a child meeting another for a moment in the street or in a shop ; 
several instances of attacks contracted in this way have come under our 
notice. The epidemics, like those of measles, appear to occur in large 
cities every eighteen months or two years. It has been asserted that there 
is some definite relation between these two zymotics, as they frequently pre- 
vail epidemically together or one immediately preceding or following the 
other ; it is very doubtful if this association is anything more than accidental, 
as they both are apt to recur every eighteen months or two years. The 
whooping cough epidemic lasts longer and more slowly reaches its height than 
the measles epidemic. Like measles, whooping cough seems to prevail at all 
seasons of the year ; but, as one would naturally expect, it is more fatal in the 
colder months of the year than in the warmer months, in consequence of the 
broncho-pneumonia which is so apt to supervene if the child takes cold. 
The mortality is mostly high among very young and weakly children, while 
in older children it is rarely fatal. During the decade 1 878-1 887, 3,669 cases 
of whooping cough were treated in connection with the children's dispensary, 
with 281 deaths, or a mortality of 7-6 per cent. Of these, 217 or 77 per cent, 
were under two years of age, 63 or 13 per cent, were from two to five years 
of age, and only one fatal case occurred in a child over five years of age. It 
is certain that these figures do not represent the total mortality, as they do 
not necessarily include those who die some months later of tuberculosis 
and gastro-intestinal atrophy. 

Incubation. — It is difficult to fix the latent period with precision, as the 
onset is gradual and the symptoms are often indefinite. It is usually seven to 
fourteen days before the child begins to cough, and another week or ten days 
before the characteristic ' whoop ' is heard. This makes an interval of two to 
three weeks between being infected and commencing to ' whoop.' 

Symptoms and Course. — The course of the disease is marked by three 
stages : (1) The catarrhal or premonitory stage ; (2) The convulsive or 
spasmodic stage ; (3) The stage of decline or convalescence. These stages, it 
is needless to say, are not well marked, but one gradually succeeds the other, 
and this is especially true with regard to the third. 



3 H The Specific Fevers 

The catarrhal stage begins with the symptoms of a feverish cold and 
tickling dry cough, which is not readily relieved by ordinary remedies. The 
cough is especially apt to recur at night, and it is remarked on by the friends 
as being more than usually troublesome, the child coughing and straining as 
if to relieve a persistent irritation in the throat. The cough keeps it awake 
at night or it wakes up coughing and fails to get to sleep for some hours. 
During the day the child may appear well, or, on the other hand, the appetite 
fails and he looks pale and poorly. The cough, if not paroxysmal from the 
first, becomes so in the course of a few days, before the actual whoop is heard. 
There is usually some degree of fever at night, and dry rhonchus may often 
be heard on listening to the chest. The first stage may be complicated with 
bronchitis or pneumonia. In young children or infants the convulsive stage 
sometimes begins with a convulsion or series of convulsions. 

The Convulsive Stage. — The cough now comes not only in paroxysms, 
but there is a distinct whoop : there are a number of short forcible expiratory 
efforts, as if an attempt was being made to expel some irritating matters, 
followed by the long-drawn characteristic inspiration which is technically 
called a 'hoop 7 or 'whoop,' or in some parts of the country a 'chink.' It is 
perhaps hardly right, at any rate when the second stage is well established, 
to speak of the expiratory coughs as ' efforts ; ' the child, prompted by a 
peculiar tickling sensation in the throat, attempts to relieve it by coughing, 
but in a moment the coughing goes on in spite of any voluntary effort to 
repress it, so that the child's face becomes congested and the facial veins 
distended, before the inspiratory act takes place, and the air rushes into the 
air-passages and lungs through the narrowed glottis. Fit after fit of cough- 
ing will often follow one another, till the child vomits or a rush of stringy 
mucus, perhaps streaked with blood, pours out of its mouth and nose. 
In the worst cases the distress occasioned by these fits of coughing 
is extreme, and the child dreads their recurrence, not only on account of 
their discomfort, but from the aches and pains it suffers, by reason of 
the over-strained and weary respiratory muscles. To a weakly child the 
disease is necessarily a formidable one ; the exhaustion produced by the 
constant muscular efforts, the frequent vomiting which prevents a proper 
amount of food from being assimilated, together with the intestinal catarrh 
which in a greater or less degree accompanies it, often reduce the' child to a 
feeble and emaciated condition. It can easily be imagined that forty or 
fifty attacks of coughing every twenty-four hours produce great muscular 
exhaustion, and affect the child's vital powers. In milder cases, where the 
fits of coughing do not exceed twelve, the child may appear quite well 
between the paroxysms, and, though perhaps vomiting after the cough, it is 
quickly ready for another meal, with sharpened appetite. Fever is mostly 
present in the second stage in variable degree, especially at night. An 
examination of the chest will generally disclose bubbling rales in the larger 
tubes, the secretion being freer than in the first stage. 

The Stage of Decline. — After a variable period of four to six weeks, during 
the latter portion of which the attacks of coughing have been diminishing, 
the characteristic whoop disappears, and convalescence may be said to be 
established. Mostly the paroxysmal character of the cough remains, and 
often the vomiting ; gradually the bronchial catarrh disappears, and the 



Whooping Cough 3 1 5 

cough ceases, though it is very likely to return, and the whoop along with 
it, whenever fresh cold is taken. 

Complications. — By far the commonest is some form of broncho- 
pneumonia ; pleurisy and empyema are not unfrequent. There is nothing 
specially characteristic about the broncho-pneumonia of whooping cough ; it 
is usually double, is very apt to be generalised rather than ' patchy,' and 
tends to resolve, or slowly passes into a subacute or chronic state. Croupous 
pneumonia is not uncommon in older children who take a chill during con- 
valescence, and may be followed by empyema. Empyema and atelectasis 
are very apt to occur in connection with bronchitis in small and rickety 
children. Young children are sometimes convulsed, the convulsions being 
due to asphyxia, and perhaps meningeal haemorrhage ; drowsiness and 
coma are usually due to the same causes. We have seen a temporary 
hemiparesis arise during whooping cough. Cerebral symptoms, whether 
convulsions or drowsiness, are of grave import. Intestinal catarrh and 
diarrhoea of a mucous character are also common ; the catarrhal condition 
of the air passages extends to the intestines, and large quantities of mucus 
are secreted, which prevent the digestion and assimilation of food, and cause 
a rapid passage of the food through the intestines, The child passes small 
mucoid stools many times a day, is feverish and rapidly wastes. Sometimes 
the diarrhoea is of a dysenteric character. Tuberculosis, especially of the 
bronchial and intestinal glands, is a sequela rather than a complication, and 
usually follows some months later. A wasting during the third stage is 
oftener due to intestinal catarrh or chronic broncho-pneumonia than to 
tuberculosis. Among the minor complications are ulceration of the fraenum 
linguae, stomatitis, and sores about the nose and lips. Small conjunctival 
haemorrhages are very common. The child often remains for a long time in 
a weakly state of health, and may take long to regain its former strength. 
Permanent deformity of the chest may remain as a legacy left by an attack 
of whooping cough. 

Diagnosis. — Often no diagnosis can be made in the early stages, and this 
is the more unfortunate as there can be no doubt that the disease is infectious 
during this stage. The fact that whooping cough occurs in epidemics will 
often aid us in coming to a conclusion. Difficulty may often arise in more 
chronic cases in which there is a paroxysmal cough followed by more or less 
of a stridulous sound, as to whether such are specific and are to go into 
quarantine. The diagnosis will turn largely on whether any cause for the 
spasmodic cough can be discovered as well as on the history ; if there has 
been previous wasting, and there is some evidence of tuberculosis of the 
lungs, enlarged mediastinal glands would be suspected as the cause of the 
spasmodic cough. Diagnosis is often difficult in infants, as also it sometimes 
is in older children, who may have whooping cough without any characteristic 
' whoop ; ' the ' whoop ' may also cease when pneumonia supervenes. 

Prognosis. — The fact that the mortality is vastly greater in children 
under two or three years of age than it is in older children must be borne in 
mind in forming a forecast of results. The prognosis in the case of an infant 
or a weakly child of eighteen months or two years of age is very uncertain, 
and death may occur suddenly during a fit of coughing from convulsions 
or spasm of the glottis. The prognosis is always rendered grave by the 



316 The Specific Fevers 

presence of broncho-pneumonia ; the latter when it follows whooping cough 
is more fatal than when non-specific. Whooping cough during the winter 
months is always more likely to be complicated with chest disease than in 
the summer ; and while this is especially true of the poorer classes, it holds 
good also to a lesser extent in the better housed classes of the population. 
The presence of rickets affects the prognosis unfavourably. The diagnosis 
between chronic broncho-pneumonia and tuberculosis and between chronic 
intestinal catarrh and mesenteric disease is very difficult ; but the tubercular 
diseases are much more likely to follow at a distance with a period of com- 
parative health intervening, while the simpler forms are more likely to 
complicate or immediately follow. A chronic pneumonia often clears up, 
and the child recovers, and a subacute intestinal catarrh may not improbably 
do the same. Death in rare cases occurs from sheer exhaustion. 

Quarantine. — Six weeks is usually stated as the time the infection lasts, 
dating from the commencement of the whoop : but in all cases it is wise to 
keep up the quarantine till all cough has ceased and the child is quite well. 
If the cough or even whoop recur after a period of undoubted health, there 
is no fear of infection. 

Pathology and Morbid Anatomy. — The epidemic prevalence of whooping 
cough and its infectious character would suggest its cause being due to 
some micro-organism. Letzerich and others have described such micro- 
organisms in the sputum of patients suffering from whooping cough : but it is 
doubtful if the actual specific bacillus has been isolated from the numerous 
micro-organisms found in the secretions of the mouth and fauces. From 
the observations of Von Herff and others who have watched the larynx with 
a laryngoscope during a paroxysm of coughing, it would appear that a 
small flake of mucus secreted from the posterior wall of the larynx was the 
excitant of the spasm. The entire larynx and trachea was in a condition 
of catarrh, the greatest irritability being in the inter-arytenoid region and the 
under part of the glottis. Some believe that the nasal mucous membrane 
rather than the lower respiratory tract is the seat of irritation, and that it is 
here that local remedies should be applied. 

No characteristic appearances are found on the post-mortem table ; the 
lesions found will vary according to the mode of death. The brain is 
usually congested, especially the veins ; there is often some subarachnoid 
fluid on the convexity and much fluid in the lateral ventricles. Various 
lesions may be found in the lungs, such as injection of the mucous mem- 
brane of the larynx and bronchi, with excessive secretion, emphysema, 
collapse, and various stages of broncho-pneumonia. 

Treatme?it. — The most important part of treatment consists in confining 
the patients to well-aired rooms which are free from draughts and maintained 
at an equable temperature. Two large! rooms should, if possible, be set 
apart for the treatment, the one occupied being maintained at a temperature 
of 6o°, while the other is being thoroughly aired or disinfected, the latter 
being again warmed before the patients are removed. There can be no doubt 
that the attack is rendered more intense and protracted by rebreathing the 
infection as well as by a fresh catarrh being set up. Except in the warmest 
weather, the patient should be confined to his rooms in the house the whole 
time the disease lasts, as long as any ' whooping ' is present, and as long as 



J J 'hooping Cough 317 

any rales or rhonchi are heard in the chest. Too great care cannot be 
exercised here ; the bronchial tubes and lungs remain exceedingly sensitive 
to cold, and many severe attacks of pleuro-pneumonia have resulted both in 
old and young from a chill caught at outdoor games or from having gone to 
the seaside for change of air. Children are much better at home until 
well over the attack, not only for the sake of others but for themselves ; and 
the pleadings of the friends for change of air must be sternly resisted until 
six weeks at least from the commencement of whooping. With regard 
to medicinal treatment, there is no lack of remedies which have been 
tried, and no disease has been more ineffectually though diligently drugged. 
It is quite safe to say that no specific has as yet been discovered. During 
the catarrhal stage, when the cough is hard, the expectoration scanty, and 
there is fever, the best remedies include small doses of antimony, ipecacuanha, 
liq. ammon. acetatis, or nitrate of potash. At night, when the cough is 
especially troublesome, hot mustardpoultices should be applied to the chest, 
and hot demulcent drinks, such as black currant tea, or barley water, or 
lemonade may be taken. Beef tea is often of service for the night, and 
a dose of hot bran dy-and- water will sometimes induce sleep. The room 
should be kept moist with hot steam if there is much bronchial catarrh 
or laryngitis. In the spasmodic stage, when the secretion is free, the ex- 
pectorants should be stopped, and sedatives and small doses of narcotics 
substituted. At this stage the diffusion of carbolic acid vapour through 
the apartment is frequently of great service ; this may be done by vaporis- 
ing strong carbolic powder in one of Calvert's carbolic vaporisers ; it is 
not certain how this acts ; no doubt to some extent it soothes by acting as 
an anaesthetic to the fauces. In a similar way cocaine or resorcin may be 
used in the form of a spray or mopped on to the fauces with a brush ; but the 
effect is usually only temporary, as the anaesthesia produced by cocaine is 
too short to be of much service. Internally we are inclined to believe that 
antipyrin, antifebrin, and phenacetin are among the most useful remedies ; 
from two to eight grains of the former being given every four hours, according 
to age, and half this dose of the last two. (F. 53). Of other drugs at this period 
belladonna, chloral, bromides, opium, cannabis indica, quinine, take the first 
place, but all at times fail to give any appreciable relief. Tr. belladonnas is 
best given in small doses every four or six hours, increasing the frequency 
rather than the size of the dose. The combination of belladonna and 
cannabis indica is a favourite one ; they may be combined as in F. 52. 

The bromides and quinine dissolved in syrup of lemons with syrup of 
Santa Yerba is also a good combination. Croton chloral is highly praised 
by Dr. Webb ; he orders a drachm of this drug to be dissolved in two ounces 
each of tr. cardamomi and glycerine, giving half a teaspoonful to two tea- 
spoonfuls every four hours to children of one to ten years. Dr. Ringer 
advises tr. lobelias, and gives doses of five to ten minims every hour even to 
young children. Opium is of all drugs the most certain to relieve ; but it is 
perhaps best reserved to be given in one dose at night : one to five drops 
of nepenthe or half to two grains of Dover's powder will often secure a fairly 
good night. The bowels should be carefully attended to, and a laxative will 
frequently be required. Unless the secretion is very copious, poultices or 
fomentations in this stage give more relief than do liniments. 



3 1 8 The Specific Fevers 

In the later stages, when the secretion is copious and the cough less and 
less spasmodic in character, nitric acid, alum, quinine, are most likely to be 
of service. Alum may be given with some sedative as conium or hyoscyamus, 
the old formula of Golding-Bird's being a good one : Alum. gr. j, succi 
conii ll| v, syrup, rhceados 1T|x, aq. anethi ad 5j ; 5j every four hours. 
Of external applications there are a goodly number which have been em- 
ployed with varying success. Equal parts of lin. camph. co., lin. saponis, 
and lin. belladonnas, used cautiously to tender skins, make a good stimu- 
lating liniment. Some have great faith in oil of amber, as in the following : 
Ol. succini 5ij, tr. opii 5ij, sp. camph. §ss, ol. amygdalae 3SS. The liniment 
of iodide of potassium and soap is useful. The diet both in the spasmodic 
and catarrhal stage should be carefully arranged, and is difficult on account 
of the vomiting so frequently present. It will often be necessary to feed little 
and often to make up for food vomited. The complications, such as broncho- 
pneumonia and intestinal catarrh, must be treated on the general principles 
given elsewhere. 

Mumps, Parotitis, — Mumps is an infectious disease which is apt to 
prevail in epidemics ; sometimes these extend over wide areas, though at 
other times cases occur and there is little tendency to spread. We have 
never noticed an extensive epidemic in hospital, but the nurses are apt to 
catch the disease from children who have been admitted incubating mumps, 
and it would seem that close contact, perhaps inhaling the affected person's 
breath, was the commonest way in which an attack was contracted. It 
sometimes happens that there is no spread of the disease in the ward where 
the affected child was, but cases have occurred in other wards, the infection 
being carried by a nurse, or perhaps by a nurse who has herself had a slight 
attack. 

Incubation. — According to Dr. Dukes, fourteen to twenty-five days. In 
some cases observed by us, it was fourteen, seventeen, and twenty-one days 
respectively. 

Symptoms and Course. — Mumps is usually a mild disease attended by 
discomfort rather than serious illness. The attack usually begins with chilli- 
ness, stiffness about the jaws, local tenderness, often neuralgic pains ; there 
is often no fever, sometimes the temperature goes up suddenly to 102 or 
103 . The swelling is at first one-sided, involving" the region of the parotid, 
which is prominent and tender ; deglutition is difficult and painful. Both 
sides are usually swollen in a day or two, and the patient presents a cha- 
racteristic appearance. The fauces and tonsils are normal. While the 
parotids are usually affected, in some cases the swelling is entirely confined 
to the sub-maxillary salivary glands on one or both sides ; it is in these 
cases that the nature of the attack is likely to be overlooked. The attack 
lasts, as a rule, from a few days to a week. Orchitis occasionally occurs in 
boys about puberty. Hemiplegia has been known to follow (Gowers). 

Diagnosis. — We have known cases of mumps sent into a scarlet fever 
ward as cases of scarlet fever, and we have also seen a case of tonsillitis with 
enlarged cervical glands, probably scarlatinal, which was diagnosed as mumps. 
In all cases of doubt as to the nature of the external swelling, the appearances 
presented by the tonsils should be decisive. The swelling due to mumps in 
the majority of cases corresponds to the parotid region, the swelling of. 



Mumps, Parotitis — Malarial Fever 319 

cervical glands secondary to tonsillar affections is at the angle of the jaw 
or just behind it. There is rarely much fever or illness with mumps ; in 
diphtheria or scarlet fever, where there is much external swelling or cellulitis, 
the child is evidently gravely ill, and if a satisfactory view of the fauces can 
be obtained, they will be seen to be swollen, cedematous, and perhaps covered 
with exudation. In adenitis, attended by fever, it is the lymphatic glands 
rather than the parotid which are affected. In spite, however, of these dis- 
tinctions, difficult and doubtful cases may occur. 1 

Treatment. — Not much is required except hot fomentations or belladonna 
liniment to the parotid regions, and a saline followed by a tonic. Three or 
four weeks, according to the severity of the case, should elapse before the 
patient returns to school or mixes with his fellows. 

Malarial Fever. — Children who live in malarial districts suffer from 
malarial attacks as frequently as do adults ; indeed, according to Holt, they 
are peculiarly susceptible. In this country many opportunities do not occur 
of seeing the disease in its early stages ; the cases which mostly come 
under observation are those which are chronic ; having acquired the disease 
abroad and having been invalided home. In these cases marked anaemia 
with enlarged spleen, and perhaps intermittent fever, form the commones 
symptoms. The anaemia is frequently profound, and the spleen attains to 
an enormous size. Nephritis as a sequela of aguish attacks is sometimes 
seen in this country. Such a case we saw with Dr. Massiah, the attack 
having been contracted in Brazil ; there was marked anaemia, enlarged 
spleen, the urine was highly albuminous, and contained fatty and fibrinous 
casts. According to Lewis Smith, intermittent fever when it affects those 
over 3^ years differs little from the adult form, while below that age it presents 
some peculiarities. Malarial fever may be hereditary, being derived from 
the mother. In one case, recorded by Lewis Smith, an infant showed dis- 
tinct symptoms a week after birth ; the mother had suffered from tertian 
ague at intervals during the two years prior to her confinement. In the 
infant the type is quotidian, rarely tertian ; there are three stages presented 
by an attack : the second or febrile is well marked, the temperature rising to 
1 04° to 106 ; the first and third less so. The spleen soon enlarges, and 
after a week or two, if the attack continues, there is marked anaemia. The 
enlargement of the spleen fails to take place in some of the cases. Dr. 
Emmett Holt, of New York, in making an analysis of the symptoms of 184 
cases of malaria in children, has pointed out how much more insidious the 
invasion of the disease is in children than in adults, and consequently there 
is more liability to overlook it and attribute the symptoms to other causes. 
Even the periodicity of the recurrence may not be regular, which would 
still more throw the physician off his guard. In his cases with a gradual 
invasion he noted anaemia, frontal headache, constipated bowels, muscular 
weakness, vomiting, furred tongue, drowsiness, and epigastric pains ; these 
symptoms usually recurring in the afternoon. The spleen was enlarged, but 
there were exceptions to this. The fever noticed by this author assumed three 
types : the first, in which the fever remained high for twenty-four to seventy- 
two hours, when a marked remission took place, the temperature then assum- 

1 Suppuration in a parotid gland may take place in enteric or pyaemia ; but this can 
hardly be mistaken for mumps. 



320 77ie Specific Fevers 

ing a remittent type ; secondly, the fever is at first slight and only present 
at one period of the twenty-four hours, but gradually increases in intensity 
and assumes a remittent type ; thirdly, assuming a distinctly remittent 
or intermittent type from the outset. Cerebral symptoms are common ; 
there are frontal headache, drowsiness, and apathy, occasionally convul- 
sions ; pains in various parts of the body ; various spasmodic disorders, 
as torticollis and motor paralysis, are less common, but sometimes take the 
form of paraplegia. Dr. Holt has also pointed out that the malarial poison 
may complicate and modify other diseases ; of these bronchitis and pul- 
monary congestion are common, the latter closely resembling pneumonia in 
the onset, but subsiding in a few hours, to come on again in the course of 
twenty-four hours. Spasmodic asthma of malarial origin may occur. Various 
gastro-intestinal disorders, as vomiting and diarrhoea, occur periodically at a 
certain time daily. The diagnosis in these cases depends upon : (i) Perio- 
dicity of the symptoms ; (2) the co-existence of splenic enlargement ; 
(3) failure of the usual remedies to relieve ; (4) their prompt disappearance 
under the use of antiperiodics. 

Treatment. — The treatment consists, as in adults, in the administration of 
antiperiodics, such as quinine, cinchonine, and arsenic. 



321 



CHAPTER XVI 

DISEASES OF THE RESPIRATORY APPARATUS 

The Thorax in Infancy and Childhood. — It is necessary when exa- 
mining the chest of an infant or child for the first time to have it completely 
bare, so that a thorough examination can be made, the infant lying in its cot 
or on its mother's lap ; care must, of course, be taken to have the room suffi- 
ciently warm, as infants readily take cold when a large surface of the skin 
is exposed, and they are very sensitive to draughts. 

On inspectio?i it will be noticed, firstly, that an infant's chest is deeper 
than an adult's, or, in other words, the antero-posterior diameter more nearly 
approaches the transverse, the ratio being 1-2 in an infant, i-i\ during child- 
hood, and 1-3 or 3^ in adults ; the horizontal section is thus more circular in 
form during infancy than in later life. Secondly, the angle which the costal 
cartilages make with the sternum is larger in children than in adults, that is, 
the lower part of the thoracic cage is widened out more ; this may be in part 
due to or accentuated by the abdominal viscera occupying a relatively larger 
space and pressing the diaphragm upwards. This is seen in an exaggerated 
form in children who have enlarged livers and constant gaseous distension 
of the stomach and intestines. Any acquired deformity should be carefully 
noted ; various rickety deformities may be present — one side of the chest may 
be contracted from an old pleurisy or empyema, or the left chest may be 
bulged outwards by an hypertrophied heart or distended pericardium. 

The way in which the child breathes should be carefully noticed. There 
may be a * crowing ' inspiration as in laryngismus, or it may be stridulous, 
there being an evident obstruction both to filling and also emptying the 
chest. The cough may have a metallic or clanging ring ; the rhythm of the 
respiratory movements may be altered, as in meningitis. 

Note must also be made of the frequency and character of the respiratory 
movements, whether deep or shallow, whether one side moves more freely 
than the other, or if there is any sinking in of the epigastrium or intercostal 
spaces and ribs during inspiration. It should be borne in mind that mere 
frequency of respirations does not necessarily mean any respiratory disease, 
but may be due to rapidity of the heart's action accompanying high fever or 
cardiac feebleness. Note also if there is any paralysis of the diaphragm or 
intercostals. The position of the cardiac impulse should be determined. 

After inspection it is usual to percuss the chest, placing one finger of the 
left hand against the chest wall and striking it with more or less force 
with the middle finger or forefinger of the right hand, taking care that the 
child lies or sits up straight, for if the body be twisted, so that one side 

Y 



322 Diseases of the Respiratory Apparatus 

bulges out more than the other, a fallacious hyper or impaired resonance may 

be produced. All the regions of the chest must be carefully examined in turn. 
Too much stress should not be laid on a slightly impaired resonance, espe- 
cially if the child is crying, unless the result of auscultation corresponds, 
and a subsequent examination confirms the result. A typical ' cracked-pot ' 
sound is readily elicited in an infant on account of the yielding nature of the 
rhest walls quite apart from the presence of cavities or any lung lesion. 
Careful note must be made of any spot where there is dulness or impaired 
resonance or hyper-resonance denoting emphysema, but bearing in mind 
that at times a 'boxy' note is elicited over lung in an early stage of 
pneumonia or acute congestion. It must not be forgotten in examining 
the chest that the diaphragm usually takes a higher position in children 
than in adults, especially when the stomach and intestines are distended 
with gas. 

In auscultation the ear may be placed directly against the chest wall, or 
(what is much more convenient) a binaural stethoscope with a small chest 
piece may be used. All parts of the chest should be carefully examined, 
noting the character of the breathing, whether the air is entering every 
part of the lungs equally, or whether the air is not entering one part freely 
while other parts are being overworked. Weak breathing may be due to an 
early stage of pneumonia, effusion of fluid, collapse of lung, compression of a 
bronchus, or a pneumo-thorax. 

' Puerile ' or harsh breathing is due to a portion of lung being over- 
worked ; it is never safe to accept it as a sign of a lesion in the lung, as 
at first a student is inclined to do, and, moreover, the breath sounds may 
appear loud and harsh to an ear accustomed only to adults. It is not uncom- 
mon in young children to note on one occasion that the breathing is weak or 
almost absent at one base and loud elsewhere, whereas after a fit of crying, 
or the next day, the weak breathing has completely disappeared ; in these 
cases a bronchus with its branches has been temporarily plugged with 
mucus, which has become displaced by coughing. Bronchial breathing is 
present in consolidation of the lung from pneumonia or tubercular infiltra- 
tion, but it is also present in the majority of cases in effusion of fluid, though 
in this case it is usually weak and distant instead of being intense and blowing. 
Cavernous or amphoric breathing is not often heard, as cavities of any size 
are rare in young children. Among the .adventitious sounds, fine crepitation 
is rarely heard in the early stages of pneumonia, the rales being mostly of 
medium size ; they may be ' consonant' or 'ringing' in character when con- 
veyed to the ear through solid lung, or subcrepitant and ill defined when the 
secretion is thick and they have to pass through normal lung to reach the 
ear. Vocal resonance, or fremitus, often gives no definite result in girls or 
young children, though when the child is crying violently the increased reson- 
ance of the voice heard over a base or apex may be of diagnostic importance. 
It is needless to add that the physical examination of young children is often 
beset with difficulties on account of their restlessness or fright, and the 
examiner may have his patience often sorely tried, and perhaps may fail to 
obtain a satisfactory examination from this cause. 

Congenital laryngeal Stridor* — It is not uncommon to meet with in- 
fants, who from their birth have made a peculiar stridulous sound during 



L aryngism us 323 

respiration, more especially during inspiration. In most cases this noisy 
respiration lasts for some months, perhaps getting worse for a while, and then 
gradually improving, so that before the middle of the second year is reached 
it has entirely disappeared. It is not dangerous to life, as is true laryngismus. 

The infants affected in this way are usually perfectly strong, and their 
health does not appear to suffer. The stridor in some cases is continuous, 
but worse when the infant is excited and breathes irregularly, and less marked 
or absent during sleep or when it is quiet. It does not become cyanotic, but 
the chest wall is frequently sucked in during inspiration and the chest tends 
to become constricted where the diaphragm is attached. Inspiration is 
laboured and noisy, expiration is comparatively easy. In some cases when 
excited and crying the hands are clenched and the thumb turned in during 
inspiration. Dr. J. Thomson describes the stridor as follows : ' Inspiration 
begins with a croaking noise and ends in a high-pitched crow, which two of 
the mothers described as being just like a hen. 5 This author is inclined to 
regard this condition as a development neurosis, like stammering. On the 
other hand, Sutherland and Lack, who examined six cases, came to the con- 
clusion that the stridor was not produced by spasm of the glottis, but at the 
upper aperture of the larynx. The aryto-epiglotidean folds which form the 
lateral walls of the upper aperture turned in during inspiration and reduced 
the aperture to a mere slit, during expiration they opened out again. It is 
this valve-like action of the upper aperture which produces the stridor. The 
action of the cords was apparently normal. If this view is correct the con- 
dition must be looked upon as a malformation rather than as a neurosis. 
Post-nasal adenoids were absent in the cases examined. This condition is 
not affected by drugs. 

In some few cases we have noted, in addition to a certain amount of noisy 
respiration in infants, there is a tendency to choke when drinking, some of 
the fluid entering the larynx by accident. This condition, though alarming 
to the friends, does not appear to be dangerous, and gradually improves as 
the infant grows older. Thus in an infant of thirteen months there is constant 
choking during the second act of deglutition when fluids are being swallowed. 
Some fluid goes the wrong way, then there is choking and spluttering. It 
could swallow ' sops : all right. This difficulty comes and goes, and is worse 
when the infant is excited. There is apparently some want of co-ordination 
of the muscles of deglutition. 

Laryngismus. Spasm of the Glottis. ' Child Crowing- ' 

The term laryngismus is applied to a peculiar form of laryngo-respiratory 
spasm which occurs almost exclusively in rickety infants. In laryngismus 
there is no lesion of the larynx, or only in a small minority of cases is there a 
laryngeal catarrh ; it is usually a pure neurosis, and it is only for the sake 
of contrasting it with other forms of laryngeal troubles that it is placed in this 
section rather than among the convulsive disorders, to which it more properly 
belongs. 

In by far the majority of cases the symptoms of rickets and chronic 
indigestion are present, but we must not in all the cases expect to find marked 
enlargement of the epiphyses, especially in infants of a few months old. 



324 Diseases of the Respiratory Apparatus 

Sometimes cranio-tabes may be detected ; usually there is some beading of 
the ribs and recession of the chest walls during inspiration. In the majority 
there is marked gaseous distension of the small intestines and pale pasty 
stools. 

The characteristic feature of the attack is a sudden ' holding of the 
breath ; for a few seconds ; then the glottis is burst open, the air rushing in 
with a stridulous sound or in a series of short ' chinks, 5 but in many cases 
there is no abnormal sound, the attack consisting entirely of holding the 
breath. The seizure closely resembles, only in an exaggerated form, the 
' catch in the breath ' which takes place as a preliminary to a good fit of 
crying, or, as Gay points out, of rage or bad temper. The condition seems 
to be as if the expiratory respiratory centre discharges for a few seconds an 
excessive quantity of nerve force, producing a spasm of the glottis and of the 
muscles of expiration, while the more powerful inspiratory centre, as it is more 
and more stimulated by the increasing venosity of the blood, strives, as it 
were, for mastery, and at length, when it succeeds, the glottis is burst open, 
and air rushes in through the narrow chink. In a severe attack not only is 
the glottis closed by the adductors of the cords, but the epiglottis may be 
felt by the finger to be spasmodically applied to the superior aperture of the 
larynx, and the respiratory muscles are in a state of spasm. 

Semon and Horsley have shown that the expiratory respiration centre is 
situated in the monkey in the cortex, 'just posterior to the lower end of the 
praecentral sulcus at the base of the third frontal convolution.' Stimulation 
of this region produces adduction of the vocal cords, and if the excitation be 
powerful enough, spasm of the muscles of the face, neck, and upper limbs. 
The same observers failed to discover any inspiratory cortex centre, but 
found that excitation of the accessory nucleus in the medulla oblongata 
evoked abduction of the cords. In rickets the nerve centres are in an 
unstable condition, and liable to liberate nerve force on the slightest provo- 
cation. In some cases many of the cortex centres discharge, and a general 
convulsion is produced ; in other cases it may be, at first at any rate, the 
expiratory respiration centre only, and a spasm of the glottis is produced. 

The exciting causes are probably many. The commonest is some emo- 
tional disturbance : a fit of crying or of anger may quickly pass into an 
attack ; fright or a sudden start may bring one on. The act of swallowing 
seems also sometimes to give rise to an attack. Dentition, irritation of the 
mucous membrane of the pharynx and larynx, nasal adenoids, constipation, 
may perhaps act as exciting causes. In a patient of ours the attacks were 
apparently worse during the time it was suffering from some aphthous ulcers 
on the soft palate. We have also seen cases which were associated with 
laryngeal and bronchial catarrh. We are not inclined to attach much 
importance to an enlarged thymus, swollen bronchial glands, or cranio-tabes 
as exciting causes. 

Symptoms. — In the milder cases, which are the most common, the child's 
inspiratory movements are accompanied by a slight 'crowing sound,' which 
does not appear to distress it, and which passes off during sleep. Some- 
times the crowing will last for days, and pass off again for some time. In 
some few cases the stridor is present during sleep as well as during the time 
the child is awake. In the most severe cases the attacks come on at frequent 



Laryngism us 325 

intervals, and are distressing in the extreme ; without warning, the infant is 
seen to screw up its face as if for a crying fit, it holds its breath, no air enters, 
and the respiratory muscles are rigid and motionless, the veins on the face 
and scalp become distended with venous blood, the face and lips become 
blue, or of a dusky tint ; then after ten or more seconds the obstruction to 
the air entering the lungs is overcome, and air rushes into the now open 
glottis. In some cases we have noted that while at first the respiratory 
muscles are quite motionless, in others, after the obstruction has lasted some 
seconds, the diaphragm begins to work spasmodically, and will often succeed 
in forcing the glottis, so that for a few seconds air is admitted at short in- 
tervals into the chest ; then for a time the attack is over, but may be shortly 
followed by another. 

These seizures, especially the more severe ones, are accompanied by 
clonic spasms of the limbs ; sometimes we have seen in these attacks the 
infant throw his hands up like a drowning man, and then, after the laryngeal 
spasm is over, the nerve discharge passes into the limbs, and the hands 
become set, as in tetany, with the thumbs turned in, and the feet in a position 
of equino- varus. 

These attacks may come on at all times of the day or night, and on very 
slight provocation. We have already referred to the most common exciting 
causes ; the most important, perhaps, is some emotional disturbance. One 
of these seizures, as we have already pointed out, is very much like what 
takes place in the early stages of a fit of crying ; the facial muscles are con- 
tracted, the mouth is open, the breath is held, the air enters the chest spas- 
modically by the contraction of the diaphragm. Herbert Spencer remarks 
that an ' overflow of nerve force, undirected by any motive, will manifestly 
take the most habitual routes ; and if these do not suffice, will next overflow 
into the less habitual ones.' We can easily understand on this principle that 
a discharge of nerve force from unstable nervous centres may take the routes 
which in infants produces a good cry, and may overflow into the muscles of 
the extremities, producing a spasmodic condition, i.e. ' tetany.' 

One point we must not forget to emphasise, and that is, that many of the 
most severe seizures are not accompanied, or rather followed, by a definite 
crowing sound. It is really the less severe ones in which the crowing in- 
spiration is best marked ; the danger necessarily depends more upon the 
length of time during which the breath is forcibly held, than upon the manner 
in which the air again enters. In many of the worst cases it is admitted 
spasmodically in sobs, and not in a long-drawn crow. 

Children who suffer from laryngismus are not only rickety, but are nearly 
always dyspeptic. There is often a difficulty in digesting cow's milk, the 
stools contain much undigested curd, and there is chronic distension of the 
bowels. They are not infrequently well nourished, as far as fat goes, but 
their muscles are poorly developed. It is unnecessary to say that it is 
artificially fed infants who are the chief sufferers from laryngismus. It seems 
very likely the unstable condition of the nerve centres are due to toxine poison- 
ing, the toxine being absorbed from the intestinal contents. The following 
case illustrates some of the points we have referred to : 

Laryngismus ; Recovery. — S. H. , aged 10 months ; admitted February 28. Mother states 
he has never been strong, has had a ' croupy congh ' since 14 days old. For the last few 



326 



Diseases of the Respiratory Apparatus 



weeks has had man}' choking fits, sometimes as many as twenty in one day. Weight, 

<> lb. 14 oz. He is .small for his age and cannot sit up; he has no teeth, fontanelles 
widely open and tense ; no cranio-tabes ; some recession of the chest walls during inspira- 
tion ; no marked beading of the ribs. When disturbed he makes a crowing sound with 
inspiration. During this time there is marked indrawing of the chest wall, lasting for a 

few moments. At other times the breath is held tightly for a few seconds till he becomes 
blue in the face. He was ordered milk, half a pint, and whey, one pint and a half daily, 
and some rhubarb and soda. March 2.— Has had many attacks of 'crowing,' and 
between the attacks there seems to be more or less constant spasm. March 4.— Ordered 
tr. belladonna; Tnjv, pot. bromidi gr. ijss, om. 4tis hor. He had six attacks yesterday ; 
no general convulsions. From this date he began to improve, the attacks becoming less. 
He went home on March 2t (weight, 10 lb. 1 oz.), having had no attacks for ten days or 
more. 

Spasm of the glottis is sometimes the cause of death in cases where the 
obstruction is not complete, as in the following case. A boy of 1 year old 
had difficulty in breathing from birth, was seized with a bad attack, and was 
admitted to hospital ; there was undoubted obstruction to inspiration and 
much recession of the chest walls, necessitating tracheotomy, which was 
followed by much relief. Death followed five hours later without apparent 
cause. At the post-mortem there were no signs of rickets ; there was slight 
congestion of the larynx and the thymus gland ; all the other organs were 
healthy. Sudden death from spasm of the glottis occasionally occurs in 
cases of tuberculosis with enlarged and caseous mediastinal glands. 

Diag?iosis. — The following table gives the chief points : 



Laryngismus : Spasm of the 
Glottis 

Occurs in rickety children 
under 18 months of age. 

No fever, and no coryza or 
laryngeal catarrh. 

Occurs at any period of the 
24 hours, and often many 
times. 

No cough, inspirations are 
stridulous. 

Contractions of the limbs, 
or general convulsions, 
not uncommon. 

The attack lasts a few se- 
conds, and frequently re- 
curs. 

Occasionally fatal. 



Spasmodic Laryngitis Membranous Croup 

[False Croup) 

Rarely occurs under 2 years Occurs at all ages during 
of age, commonest 2-7 childhood, 

years. 



Slight fever, mostly coryza 
and laryngeal catarrh. 

The attack occurs at night. 



Variable amount of fever, 
and perhaps some diph- 
theria of the fauces. 

Mostly worse at night. 



Metallic cough, stridulous Metallic cough, stridulous 
respiration, variable dys- respiration, -progressive 

pneea. dyspnoea. 

Convulsions rare. Convulsions rare. 



Attack passes off in the Becomes steadily worse, 
course of an hour or two. though variations occur 

in its progress. 
Rarelv fatal. Very often fatal. 



Prognosis. — The great majority of infants who suffer from ' child crowing ' 
recover ; the prognosis, however, must always be a guarded one, and as long- 
as there is any tendency to spasm of the glottis the child cannot be regarded 
as out of danger. A ' crowing ' child may at any time have general convul- 
sions and die in a few moments. Improvement in the child's general condi- 
tion, and especially of its digestive powers, quickly leads to an improvement 



Laryngismus — Spasmodic Laryngitis 327 

in the ' crowing ; ' this we have noticed in several cases which rapidly im- 
proved under the careful feeding and attention in the hospital, but which 
quickly relapsed again when they were discharged. An attack of bronchitis 
or broncho-pneumonia is very likely to prove fatal in a child subject to 
laryngismus. 

Treatment. — During the spasmodic stage when the breath is being held, 
every effort must be directed towards exciting reflexly the inspiratory respira- 
tory centre. A sponge well wetted with cold water may be dashed into the 
face : patting on the back, or a vigorous shake, will sometimes be successful. 
It is useful to have a hand fan within reach, and use it vigorously during an 
attack to fan the face. 

We have found that hooking back the epiglottis with the forefinger has 
been followed by an inspiration. In one of our own cases a child who was 
subject to these attacks had a severe seizure while under chloroform for the 
removal of post-nasal adenoids, and his life was only saved by the rapid 
performance of tracheotomy. In such cases a catheter passed into the 
larynx would suffice to insure the entry of a small quantity of air. 

The first indication for treatment is to give a dose of calomel gr. \- — gr. i, 
to act on the bowels and clear away all decomposing milk foods. The most 
useful medicines for temporary use to keep the attacks in check are chloral, 
bromide, and minute doses of morphia. We should only give these drugs in 
the severe forms of spasms in order to soothe or render less irritable the 
unstable state of the nervous system. Five grains of bromide with two and 
a half of chloral may be given to an infant of nine months, and repeated every 
six hours. A drop of liq. morphine may be given every six hours, its effect 
being carefully watched. 

The most important part of the treatment is with regard to the diet and 
surroundings of the child. It is of the greatest importance that it should 
get fresh air. A steam tent or hot close room is the Avorst possible place 
for an infant suffering from laryngismus. A change away to the seaside often 
works wonders, by improving the infant's digestive powers and general health. 
A food or foods must be found and given in quantities which the child can 
digest. It will probably be found that the child is taking more milk than it 
can digest, and is passing large pasty stools. The amount of milk must be 
diminished. Peptonised foods, cream mixtures, thin oatmeal gruel, beef juice, 
beef tea with vegetables, all have their value in these cases, if given in 
suitable quantities according to the child's digestive powers. Medicines 
which assist the digestion and regulate the bowels are often necessary ; 
extract of malt, rhubarb and soda, acids and pepsine, and, above all, cod liver 
oil, when it can be taken and digested. Constipation must be removed. If 
a child has laryngismus and post-nasal adenoids, is it safe to operate ? We 
have several times operated with great advantage ; but it is necessary to be 
on the look-out for spasm of the glottis. Intubation may be performed or a 
catheter passed into the trachea, if necessary, and artificial respiration 
performed. 

Spasmodic laryngitis. Catarrhal Spasm 1 . False Croup 

This affection differs from the last described in that it consists in a sudden 
but not complete stenosis of the glottis associated with a laryngeal or pharyn- 



328 Diseases of tJie Respiratory Apparatus 

geal catarrh. A child, usually above 2 or 3 years of age, goes to bed 
apparently well, or there maybe a slight hoarseness or cold in the head; 
after a few hours' sleep he is suddenly awakened with alarming symptoms of 
laryngeal obstruction. There is a loud metallic cough, stridulou^ respiration, 
more especially with inspiration, the dyspncea and distress are very great, 
there is recession of the chest walls, and all the accessory muscles are called 
into requisition. The orthopncea and distress are so great that death seems 
imminent. In the course of a few minutes, probably before the arrival of 
medical assistance, which is hastily summoned, the laryngeal obstruction 
has ceased, and the child, tired out by its unwonted exertions, falls into a 
quiet sleep. The symptoms of a catarrh or tracheitis persist for some days, 
perhaps with some clanging cough and more or less pronounced attacks of 
dyspncea at night. Children who thus suffer are extremely liable to a re- 
currence whenever they take cold, and it is not uncommon for mothers to say 
that their child is very subject to ' croup.' Though these attacks are alarming, 
they are rarely fatal, thus contrasting with laryngismus ; but it must be re- 
membered that the latter is frequently associated with general convulsions, 
and, moreover, occurs at an age when spasm of the glottis is necessarily 
dangerous if severe on account of the weakness of the respiratory muscles 
and want of rigidity in the chest walls. Children who have chronically 
enlarged tonsils or nasal adenoids are exceedingly apt to suffer from 
spasmodic laryngitis. 

These attacks of spasmodic croup differ very much in severity ; in some 
cases they are very mild, but on account of their occurring at night, 
and the dread in w-hich all forms of croup are held, they are exceedingly 
apt to alarm the friends. Several children in the same family may suffer, 
and there is often a history of these attacks to be obtained in other members 
of the family. 

Treatment. — Great care should be exercised to protect children subject 
to such attacks from cold. A damp house or a damp situation should be 
avoided, and exposure to the cold east winds of spring should be carefully 
guarded against. Great benefit is usually derived from residence at the sea- 
side. Cold sponging with tepid salt and water every morning on getting up 
will greatly assist in keeping the child free from attacks. Warm woollen 
clothing should be worn next to the skin, and care taken that the- legs and 
neck are well protected. Enlarged tonsils or adenoids must be removed. 
During the attack most relief is given by applying hot sponges to the throat 
and by administering an emetic of ipecacuanha powder (5 to 10 grains) or a 
teaspoonful or two of ipecacuanha wine. As the child gets older he becomes 
less and less liable to these attacks, which cease altogether before puberty is 
reached. 

Compression of Trachea. Spasm of Glottis 

An abscess or tumour in the posterior mediastinum may compress the 
trachea within the chest and give rise to obstruction to the entrance of air 
into the lungs and also spasm of the glottis. The symptoms of such an event 
are a ' metallic ' or ' croupy ' cough, noisy stridulous breathing, orthopncea and 
attacks of difficulty in breathing, especially at night. Later, probably, there 
will be noted marked obstruction to the entrance and exit of air to and from 



Compressioji of Trachea — Catarrhal Laryngitis 329 

the chest. There may, in addition, be choking attacks, or difficulty of 
swallowing from pressure on the oesophagus, and dilated jugular veins from 
obstruction to the venous circulation. The compressing abscess may arise 
from caries of the bodies of the upper three or four dorsal vertebrae, from the 
mediastinal glands or thymus. Lympho-sarcoma of the mediastinal glands 
may give somewhat similar symptoms. The following cases illustrate 
mediastinal abscesses. {See also Spinal Caries.) 

Tubercular Abscess of the Thymus; Pressure on the Trachea; Tracheotomy. — 
Margaret S., aged 20 months ; admitted November 24, 1892. Mother states she has been 
weakly from birth and subject to bronchitis. Five days ago she began to cough and 
breathe with difficulty. Sweats a good deal, and cannot lie down ; her lips are blue at 
times. On admission the child was cyanosed and there was much orthopncea ; she was 
given three teaspoonfuls of vin. ipecac, in divided doses, but she was not sick. A few- 
hours after tracheotomy was performed by Mr. Westmacott, but it failed to relieve the 
breathing, and she died two hours after. Post-?nortem. — -On removing the sternum an 
enlarged thymus was noted, extending from the upper border of the sternum to the bifur- 
cation of the trachea, and lying in contact with the trachea, and evidently compressing it. 
Some caseous lymphatic glands were adherent to the mass. On section it was found to con- 
tain a large abscess cavity filled with thick pus. There were some miliary tubercles and 
broncho-pneumonia in both lungs. 

Caries of Cervical Spine ; Abscess compressi?ig (Esophagus and Trachea. — Richard L., 
aged 3 years ; admitted February 19, 1894. Mother states for the last fortnight he has 
had a barking cough and wheezing ; he gets feverish and restless at night. On examination 
it was noted he had a harsh metallic cough and husky voice ; prolonged expiration and 
rhonchus all over the chest. March 19. — For the last week the breathing has been much 
worse, noisy, and markedly stridulous ; the cough metallic, and some recession of the 
chest. April 11. — Breathes with a croupy sound ; has attacks of difficult breathing at 
night ; gets blue and distressed. Air enters the chest with a long-drawn sibilant sound, 
is held, and then slowly goes out. Resonance is boxy over the sternum. Face puffy ; 
no enlarged veins. May 14. — Lips and fingers somewhat cyanosed. Sits up if awake, 
but when asleep lies down, though always raised more or less on pillows. Swallows 
solids and liquids fairly well. Jul}- 10. — Temperature been irregular since last note ; 
varies 97 to ioo°. Breathing has improved of late ; there is a tendency to choke when 
he feeds. September n. — All laryngeal symptoms have disappeared. Chokes when he 
feeds ; no post-pharyngeal abscess ; no pain in the neck, but he cannot hold his head up, 
and the last two cervical vertebrae are very prominent ; he cries with pain if his head is 
rotated. Temperature 98 to 101 . October 13. — Much worse ; for some time past has 
been wasting ; hectic temperature ; had a bad attack of dyspnoea early this morning ; 
much vomiting, pus running from nose and mouth. Death October 23. Post-mortem. — 
Mediastinal glands enlarged, but not caseous ; a small cicatrix at the apex of left lung ; 
bronchitis, but not tubercle. In upper part of the posterior mediastinum, and behind the 
oesophagus is an abscess cavity holding about sij ; it has compressed the oesophagus and 
opened into it. The trachea has been flattened for a couple of inches opposite the abscess. 
Posterior w r all of abscess cavity formed by spinal meninges in position of seventh cervical 
and upper three dorsal, the bodies having completely disappeared. 



Catarrhal Laryngitis 

Children of all ages are liable to suffer from a catarrh of the larynx and 
trachea, though it is perhaps most common and is certainly most dangerous 
during the first two or three years of life. These attacks differ somewhat from 
those of spasmodic croup just described, inasmuch as there may be no violent 
exacerbation at night, yet in many cases all the symptoms are apt to be worse 
towards evening. In both cases there is laryngeal catarrh and laryngeal 



330 Diseases of the Respiratory Apparatus 

spasm, and they differ only in degree : in the spasmodic variety there is 
usually little catarrh, but severe attacks of spasm of the glottis; in the 
catarrhal variety the catarrh is much more severe, and perhaps the spasm is 
not well marked, but all these cases are apt to become much worse at 
night, apparently from the presence of more or less spasm. They are 
mostly the result of cold, exposure to cold winds or a chill, and they may be 
associated with measles, either belonging- to the premonitory symptoms, or 
following the disappearance of the rash. The attacks are preceded for the 
most part by coryza, feverishness and cough, the first suspicious symptom 
being the changed character of the cough, which is at first hard or hoarse, 
and then assumes the characteristic 'croupy'or 'brassy' character, which 
announces that there is some stenosis of the larynx. An examination of the 
fauces will probably show enlarged and congested tonsils with excessive 
secretion, and if the epiglottis can be seen, the mucous membrane will be 
found to be of a pinker colour than usual ; but it is rarely possible to get a 
view of the larynx by means of the laryngoscope. As the symptoms become 
more marked, the air is heard to enter the larynx with a hissing sound, there- 
is dyspnoea, the alae nasi work, the chest walls fall in during inspiration, and 
there is often much distress. In some cases the child has to be propped up 
in bed, and pays no heed to its toys, its whole attention being taken up in its 
efforts to breathe. The fever is variable, rarely high, usually ioo° to ioi° ; 
the pulse is quick and hard. In most cases the symptoms are milder than 
those just described, there being only a croupy cough and some acceleration 
of breathing. In the later stages the secretion becomes freer and muco- 
purulent. On the other hand, the case may become so urgent that intubation 
or tracheotomy is required to stave off impending death, though usually the 
effects .of treatment render this unnecessary. Cases of simple catarrhal 
laryngitis in children rarely present the picture of stenosis of the larynx 
which is seen in the membranous variety ; there is probably the 'croupy' 
cough and frequent breathing, but between whiles, especially after a fit of 
coughing, the child is comparatively comfortable, and falls into an easy 
sleep. The prognosis depends upon the diagnosis ; if the case is one of 
catarrhal laryngitis and the child is over 2 or 3 years of age, there is strong 
probability that it wall recover. The younger the child, the greater is the 
danger. 

Treatment.— -The first appearance of ' croupy ' symptoms should never be 
neglected ; the hard metallic cough, when once heard, should be the signal 
for placing the child in a warm room, where the temperature is maintained 
at 6o° or 65 both day and night, giving at the same time fluid food or sops, 
demulcent drinks, and medicines which promote diaphoresis. If the sym- 
ptoms become more pronounced, the child must be confined to its cot, and a 
tent rigged over it by means of sheets stretched over cords or a clothes- 
horse, so as to protect the patient from draughts, and a moist atmosphere 
must be secured by the aid of the steam kettle. Some carbolic acid or tr. 
benzoin co. may be placed in the kettle. The temperature inside the tent 
should be maintained at about 70 , and steam from a kettle allowed to play 
freely into it, so as to render the air thoroughly warm and moist. The usual 
tendency of the friends of the patient is to overdo the steam and maintain 



Catarrhal Laryngitis 331 

too high a temperature, so that it is not uncommon to find the patient almost 
parboiled. 

During the early stages of laryngitis, when there is much swelling of the 
mucous membrane of the larynx, with little secretion, the steam gives more 
or less, at least temporary, relief. This is most marked in the cases of hospital 
patients who have been much exposed before being admitted ; in these cases 
the amount of relief given by the steam tent is often an important element in 
the diagnosis of catarrhal versus membranous croup. A steam kettle should 
be heated by means of a spirit lamp rather than by gas or by placing it on 
the fire, as in the latter case the patient's cot has to be placed close to the 
fire. The products of the combustion of gas are objectionable, especially in 
a small room. Local applications applied over the larynx in the form of 
hot sponges or spongio-piline wrung out of hot water are often of much 
service. The sponges should be taken out of the hot water and squeezed 
by wringing in a piece of flannel and used continuously ; but if this exhausts 
the child too much, a piece of spongio-piline may be secured in situ by tapes 
and renewed every half-hour. An emetic in this stage is often of much 
value in relieving the breathing and producing free expectoration, ipe- 
cacuanha powder answering very well. Five grains may be given in syrup of 
orange peel every ten minutes till vomiting is produced. Sulphate of copper 
in gr. \ to gr. \ doses, repeated in a few minutes, will generally produce 
vomiting. It is useless to repeat emetics if they fail to give relief. It need 
hardly be said that it is wrong to give emetics in the later stages, when the 
breathing has become laboured and the lips blue or pallid ; to give emetics 
under these circumstances is to risk failure and to waste invaluable time. Of 
medicines, antimony unquestionably holds the first place, and in sthenic cases 
should be given with a free hand, though as an emetic it is too slow and 
nauseating. Either the wine or tartar emetic may be given, in combination 
with citrate of potash or acetate of ammonia. (F. 46.) Tartar emetic may 
be given in powder or in l tabloids,' gr. -^ to gr. T V every two or three hours, 
according to age. Both ipecacuanha and aconite in small and repeated 
doses are useful. 

The only food admissible is milk diluted with barley water or soda water, 
preferably given warm to assist in producing perspiration. In most cases of 
catarrhal laryngitis relief of the most urgent symptoms follows this line of 
treatment, though probably for several days many of the symptoms will 
remain, with exacerbations at night ; in such cases the antimony may be 
pushed, nauseating doses being given. 

The question as to whether intubation or tracheotomy should be per- 
formed is always a difficult one, inasmuch as in many cases the most urgent 
symptoms will disappear under the influence of treatment, and the operation, 
even in the most skilful hands, adds another element of danger to the case. 
It is impossible to lay down any rule for the performance of the operation, 
or to select any one symptom which is to be taken as the signal. Dyspnoea 
and recession of the chest wall do not necessarily indicate any immediate 
danger, and most of us will have seen cases in which there has been indrawing 
of the epigastrium and ribs recover without operation. If, however, the case 
passes into a later stage in which the voice almost disappears, the respiration 
becomes laboured, all the respiratory muscles joining in the attempt to draw 



33 2 Diseases of the Respiratory Apparatus 

in air and expel it from the chest, while the distress and restlessness are on the 
increase, it is then quite certain that the time has come for affording relief. 
If there is marked pallor of the face, coma, delirium, or other symptom of 
toxaemia, there is not a moment to lose. 

The difficulty is in large measure due to the uncertainty of our diagnosis. 
If we are sure that we are dealing with a case of catarrh pure and simple, 
even though the symptoms of obstruction are threatening, we can afford to 
wait, and give our treatment a fair trial before proceeding to operate, know- 
ing that much of the obstruction is due to spasm, which may at any time 
suddenly subside. Death from asphyxia must be very rare in a case of 
catarrhal laryngitis over two or three years of age. But it is comparatively 
seldom that we can make a certain diagnosis — at first, at any rate — between 
catarrhal and diphtheritic laryngitis, as it may be only after tracheotomy 
has been performed, and sometimes even a day or two later, that membrane 
is coughed up. It is often not easy to decide as to the time for operative 
interference, but in a case where there was a history of the child having 
suffered before from ' croup,' and where the breathing tended to get worse 
at night and afterwards improved for a while at least, we should delay 
operative interference as long as possible, in the hope that improvement 
might take place. On the other hand, in a case that steadily got worse with- 
out any intermissions, we should certainly advise operative interference in 
good time, as there would be little chance of a successful issue to the case 
unless the obstruction were relieved. 

Diphtheria of the Air Passages 

Is membranous laryngitis always diphtheritic? Can there be diphtheria 
of the larynx without membrane being present? In the great majority of 
cases there can be no doubt that if membrane be present on the tonsils, epi- 
glottis or larynx, the case is one of diphtheria ; but it cannot be said, with cer- 
tainty, if there is no membrane there is no diphtheria. In the present state of 
our knowledge it is not wise to take up a dogmatic position, except in so far as 
to view every case of laryngitis, whether we find membrane or not, with the 
greatest suspicion, as such cases may turn out in the end to be diphtheria, and 
we may regret when too late that we did not at first inject antitoxic serum. 
Every case of membranous laryngitis should be treated as diphtheria. 

Symptoms. — The initial symptoms of membranous croup, whether diph- 
theritic or not, are practically identical, inasmuch as they are those of stenosis 
of the larynx. When the larynx is the primary seat of the attack the symptoms 
are those of catarrh, with restlessness, feverishness, and brassy cough. In 
the course of a day or two, sometimes sooner, there is more or less loss of 
voice and the cough has a peculiar ringing or metallic character, which is 
very characteristic. 

It now becomes evident that there is some obstruction in the larynx, as 
the air enters the trachea with a hissing or stridulous sound, and the child 
is constantly endeavouring to cough something up and clutches at its neck as 
if to remove some obstruction. The tonsils are usually swollen, the fauces 
reddened, and perhaps the seat of false membrane. There is marked rest- 
lessness ; the child wants to be nursed, then put back again into its cot, 



DipJitJieria of the Air Passages 333 

perhaps get a few minutes' sleep, waking' up with a hoarse cough and difficulty 
of breathing. The voice now is nearly lost, the child speaking" in a whisper 
and making itself understood with difficulty. There is marked dyspnoea, 
which tends to increase as the disease progresses ; the alae nasi dilate, the 
extra inspiratory muscles are called into action, and the epigastrium and in- 
ferior lateral region of the chest, the intercostal spaces, and supra-sternal fossa 
are drawn in during inspiration. The expiratory efforts are laboured, so that 
the abdominal muscles act with some force, and the air escapes through the 
larynx with a noisy sound. So laboured and noisy is the breathing that it 
can be heard some distance off. While the child goes from bad to worse, 
there are usually more or less marked exacerbations ; the child is easier 
after a fit of coughing, during which mucus or perhaps some membrane is 
actually dislodged. All the symptoms are apt to be worse at night. 

If no relief is obtained the symptoms of toxaemia begin to present them- 
selves. There is a marked pallor or lividity about the lips and face ; per- 
spirations break out on the forehead ; the restlessness is often intense ; the 
child is perhaps drowsy and delirious, perhaps attempting to get out of bed ; 
presently complete insensibility comes on, the pupils dilate, the attempts at 
respiration become more and more feeble, and death quickly ensues. The 
temperature is usually raised a degree or two in the earlier stages, but may 
be subnormal as the blood becomes more venous. An examination of the 
chest does not always yield positive results as to the state of the lungs. The 
whistling or stridulous sound produced in the larynx is heard all over the 
chest, masking the vesicular breath sounds, and making it difficult to 
diagnose the condition of the lung. The supraclavicular regions in front are 
usually unduly resonant from the presence of emphysema, while at the bases 
posteriorly the resonance is mostly impaired on account of the lung being- 
collapsed, or air entering it very imperfectly. The diagnosis of pneumonia 
is difficult in the absence of impaired resonance, as the typical signs maybe 
wanting on account of the small supply of air entering the chest : moreover, 
the pneumonic consolidation may be masked by emphysema. It is difficult 
to diagnose the presence of membrane in the trachea and bronchi ; but if 
after tracheotomy has been performed the breathing is still laboured with 
indrawing of the chest walls, there will be strong reason to suspect that the 
bronchi are obstructed by membrane. 

When the larynx is affected secondarily the symptoms are frequently 
much less marked, more especially if the membrane only spreads to the 
larynx after it has existed for some days in the pharynx or nasal mucous 
membrane. In this case the weakness and depression which exist before 
the laryngeal complication supervenes mask the symptoms of laryngeal 
stenosis. There is usually much less dyspnoea and distress than when a 
healthy child is suddenly attacked. When the primary seat of the membrane 
is in the bronchi and it ascends to the larynx, the symptoms closely 
resemble purulent bronchitis, as in the following case : 

Ascending Diphtheritic Croup. — Thomas Mac, 7 years. Boy was quite well till 
February 8. He complained of his throat, and became hoarse ; he had also a cough. 
On February 8 he came to the Manchester Throat Hospital, where examination showed 
the cords and larynx were healthy. February 11. — Seen by Mr. Westmacott at the 
Children's Dispensary ; hoarseness and signs of bronchitis were noted, and he was sent to 



334 Diseases of the Respiratory Apparatus 

hospital. On admission he is a well-nourished boy, some dyspnoea, but a good colour. 
There is recession of the lower part of the chest. Pulse, too; respiration, 28: tempera- 
ture, 99'8 ; chest resonant. Rhonchi heard all over chest. No enlarged glands to be 
felt; some diffuse redness of fauces ; no membrane. Steam tent; sick twice after pulv. 
ipecac, gr. xv. February 12. — There is more marked recession than yesterday ; spits some 
purulent sputa ; rales heard in chest. At noon, intubation by Mr. Lea, coughed up much 
stringy mucus. Temperature 98°-ioi° ; no membrane. February 13. — Respiration 
tube remains. Temperature 101 . February 15.— Tube removed; breathes easily, but 
coughs up a good deal of greenish pus. Urine contains a trace of albumen. February 16. 
— Respiration easy ; no recession ; urine a large amount of albumen. Intubation at 10.45 '< 
coughed tube up in a few minutes. Intubation again at 1 P.M. ; much muco-pus coughed 
up. February 17. — Child much worst- great pallor. Respiration 32. Urine scanty; 
large amount of albumen ; weak pulse, low tension. February 18. — Tracheotomy this 
morning, dyspnoea increasing; no membrane seen. Child died of asthenia early morning. 
Post-mortem. — Thin membrane extending down the trachea and bronchi to the smallest 
bronchi in the lungs ; much mucus present. Some membrane on the epiglottis and larynx ; 
none on the fauces or nares. 

Albuminuria exists in a large number of cases in the early stages, in 
nearly all in the latter stages ; the urine may be highly albuminous and 
scanty. Occasionally there may be suppression of urine and uraemic sym- 
ptoms. 

Diagnosis. — The diagnosis of stenosis of the larynx is not difficult, nor is 
it likely to be confounded with bronchitis or broncho-pneumonia where the 
obstruction resides in the bronchial tubes, or where there is extensive con- 
solidation of the lung. In laryngeal stenosis the air rushes through the 
larynx, giving rise to a crowing or stridulous sound, especially during inspira- 
tion, but there is obstruction to the expiration also ; the respiratory move- 
ments are laboured, as if to overcome the obstruction, and with this there is 
marked recession or sucking in of the chest walls during inspiration. There 
is loss or great impairment of voice. In pneumonia or bronchial obstruc- 
tion, the dyspnoea may be great and the respirations frequent, with much 
indrawing of the chest wall, but there is no stridor or loss of voice. The 
diagnosis of obstruction of the bronchial tubes, in addition to stenosis of the 
larynx, as in those cases where the membrane has spread downwards or 
where there is an accumulation of mucus below the larynx, is difficult and 
uncertain ; but in all such cases the dyspnoea will be great, and tracheotomy 
urgently required, and the presence of obstructed bronchi would not contra- 
indicate operation, as an opening in the trachea would favour the coughing 
up of the obstructing material. 

The diagnosis between diphtheria and non-diphtheritic croup is often a 
matter of difficulty by clinical observations alone, and until the case has 
remained under observation for some hours or days often impossible. Even 
after tracheotomy has been performed, the nature of the case may still be 
doubtful, inasmuch as thick fibrinous mucus may be coughed up with no 
distinct membrane, and recovery may take place without the diagnosis having 
been determined. The question of diphtheria or not diphtheria is one of the 
greatest importance, but unfortunately there is not much that can be said 
with certainty. It is easy to say that in diphtheritic croup there is asthenia, 
while in catarrhal laryngitis the attack is sthenic in nature. But, as a 
matter of fact, it occurs in practice that if the primary seat of the diphtheria 
is the larynx, the first and only symptoms are those of stenosis of the larynx, 



Diphtheria of the Air Passages 335 

and the pallor and depression and asthenia which result are due to the 
toxaemia produced by want of oxygen, rather than by the working of the 
diphtheritic poison. It is for this reason that the symptoms of membranous 
formations are practically the same whether produced by diphtheria or not. 
If, however, the larynx is affected after the existence for some days of 
diphtheria of the fauces, the symptoms are necessarily modified. The 
diagnosis of diphtheria when primarily situated in the larynx has often to be 
made less from the symptoms of the patient than from his surroundings. 

If diphtheria is epidemic at the time, or if the fauces are covered with 
membrane, or there is albumen present in the urine, the case is almost cer- 
tainly diphtheritic. The discovery of Loeffler's D-bacillus in the secretions 
would place the diagnosis beyond doubt, and in every case with suspicious 
laryngeal symptoms a swob should be taken and submitted to a competent 
bacteriologist. This, however, in any case takes time, and it is not always 
possible, especially in country districts, to obtain the services of a skilled 
bacteriologist. 

Stenosis of the larynx may be caused in other ways than by the exudation 
of membrane ; the larynx may be compressed by an abscess situated pos- 
teriorly between the larynx and oesophagus, or even laterally ; in this case 
there will be difficulty of swallowing as well as dyspnoea. The trachea may 
be compressed below the larynx by an enlarged thyroid or new growth, but 
the history of the case as well as the local enlargement would distinguish 
between the two. In infants and young children spasm of the glottis will in 
rare cases simulate membranous laryngitis, as in the case given (p. 326). 

Pathological Anatomy. — The post-mortem appearances found in those 
who have died of membranous or diphtheritic croup differ according to the 
immediate cause of death. In the majority of cases this is due to the forma- 
tion of membrane below the tracheotomy wound and to the lungs becoming 
choked or collapsed. In such cases membrane may be found beginning 
at the epiglottis and extending downwards to the smallest bronchi. As a 
rule the membrane is tough and firmly adherent to the epiglottis and larynx, 
being separated with difficulty, while lower down the membrane is far less 
tough, and is much more easily detached ; the bronchi usually contain semi- 
purulent fluid, and the bases of the lungs are usually pneumonic or collapsed 
while the apices are emphysematous. In some cases death results from 
asthenia or from septic poisonings, the result of the diphtheritic infection ; in 
such cases the trachea and bronchi may be free from secretion. It is ex- 
ceedingly rare to find at the post-mortem that the membrane is confined to 
the larynx in those cases where tracheotomy has been performed. Broncho- 
pneumonia is frequently present. 

Treatment. — Every case of laryngitis occurring in a child should be at 
once isolated, as what may appear in the early stages to be a mild case of 
catarrhal laryngitis may in the end prove to be diphtheritic. There are mild 
attacks of diphtheria of the larynx, just as there are mild cases of diphtheria 
of the tonsils and fauces. In the early stages the secretion coughed up may 
be muco-purulent only, and later, either before or after tracheotomy or in- 
tubation has been performed, the secretion may be membranous. 

In every case of laryngitis where there is even a suspicion of diphtheria 
1,000 to 1,500 units of antitoxic serum should be injected without delay. It 



336 Diseases of the Respiratory Apparatus 

may be impossible to make a diagnosis of diphtheria in those cases in which 
the larynx is first attacked, but inasmuch as diphtheria of the larynx is an 
exceedingly fatal disease, and as the success of the serum treatment depends 
upon it being - begun within 24 or 48 hours of the commencement of the 
illness, it is better to err on the safe side and treat a suspicious case as 
diphtheria from the very first. If in a case, seen for the first time, there is a 
whitish or yellowish exudation eitherinpoints orpatcheson the tonsils or fauces, 
we should not hesitate to use antitoxin. Our experience agrees with that of 
others, that in some cases, at least, improvement in the symptoms takes place 
within 12 or 24 hours, and in cases in which tracheotomy is necessary, the 
mortality is less now than formerly it was without antitoxin. The antitoxin 
apparently has the effect of loosening the membrane and preventing extension. 
Goodall comes to the conclusion, from the consideration of the statistics of 
various institutions, that out of every 100 cases of tracheotomy for diphtheria 
in the preantitoxin days not more than 29 were saved, now at least 53 recover ; 
and in those cases not operated on in the old days not more than 48 recovered, 
now at least 75 cases end in recovery. 

Much that has been said under the head of treatment in catarrhal laryn- 
gitis will apply to the treatment of diphtheritic laryngitis. A steam tent 
should be provided, and warmth and heat should be applied externally to 
the larynx, though any blistering or abrasion of the skin must be carefully 
avoided. If the case is certainly one of diphtheria, we doubt the value of 
either emetics or expectorants. If there is membrane in the larynx there, is 
small chance of its being loosened or detached by these means. We must 
chiefly rely on the application of steam from a steam-spray apparatus 
charged with some antiseptic, and, above all, on antitoxin in relieving the 
stenosis of the larynx by intubation or tracheotomy. Calomel fumigation 
has been used with some success in America, and is certainly worth a trial. 
Dr. Northrup recommends that a tent be rigged up over the cot by means 
of sheets, made fairly air-tight, and of about 50 cubic feet capacity. 1 5 grains 
of calomel are volatilised every two hours for two days and two nights, and 
then at intervals of three hours for the next twenty-four hours. The calomel 
is volatilised by means of a tin plate heated by a spirit lamp, and placed over 
a bowl of water so as to prevent fire in case of an upset. This treatment does 
not produce ptyalism ; if carried on too long stomatitis, diarrhoea, and anaemia 
may supervene. The mouth should be kept swabbed out, and any secretion 
coughed up must at once be removed and disinfected. The medicinal treat- 
ment appropriate for diphtheria should be given (see infra). The only food 
should consist of fluids. 

Tracheotomy. — The operation of opening the trachea in cases of mem- 
branous laryngitis must be looked upon as a means of relieving the mecha- 
nical obstruction to respiration ; it can in no way influence the constitutional 
effects of the disease, though it may prevent the addition of gradual asphyxia 
to the other depressing influences of the poison. Further, we may, by the 
operation, prevent the spread of the membrane down the trachea, and thus, 
perhaps, lessen the risk of absorption of the virus as well as get rid of the 
obstruction. 1 What certainly may be looked for from the operation is that 

1 Vide R. W. Parker. 



Diphtheria of the Air Passages 337 

death from mechanical obstruction to the upper segment of the windpipe may 
be averted, and that the distress caused by dyspnoea may to a great degree 
be relieved. It must not be forgotten that tracheotomy has its own dangers : 
first come the risks of the operation itself — haemorrhage, injury to important 
neighbouring structures, and entrance of blood into the trachea ; later, there 
are the dangers of septic absorption, the exposure of a raw surface to the 
diphtheritic poison, tracheitis, pneumonia, and so on, from exposure of the 
tracheal mucous membrane to cold ; that this is a real danger a paper of 
Sir S. Wilks shows. 1 

While we have thus indicated the objections to and the limited uses of 
the operation, we would yet urge its performance in all cases where there is 
severe dyspnoea ; we have no means of knowing that the child will die of 
asthenia, we do know that he will die of suffocation if unrelieved, and the 
other dangers mentioned are all usually avoidable by careful operating and 
after-managem ent. 

Extreme prostration without distinct evidence of asphyxia, and the pre- 
sence of pneumonia or capillary bronchitis, may be looked upon as indica- 
tions that tracheotomy will be of no avail. If tracheotomy is otherwise in- 
dicated, the presence of bronchitis may not in all cases prevent the operation 
being successful. We have seen a case in which it succeeded perfectly under 
these circumstances as far as relieving the dyspnoea went, though the child 
died, when apparently convalescent, from ulceration into the innominate 
artery. 

The younger the child the earlier should tracheotomy be done ; indeed, 
in children under three years once there is membrane in the larynx there 
is little hope but in tracheotomy ; but see p. 336. Inasmuch as the operation is 
nearly always one of urgency, we must be prepared to do it under unfavour- 
able circumstances as regards nursing, light, help, and appliances. It is, 
however, usually possible to improvise fairly serviceable arrangements for 
the operation itself. A dressing table or the top of a chest of drawers 
in private houses is the usual operating table. Candles give generally 
the best obtainable light when, as is so often the case, the operation has to 
be done at night, and care must be taken that the lights are entrusted only 
to those members of the household who can be depended upon to bear seeing 
the operation. These makeshift arrangements, together with the small size 
and anatomical relations of the parts, the urgency of the case, and the 
movements of the trachea in difficult respiration, make this operation, 
though often lightly spoken of, one of the most anxious in surgery. 

If possible, at least one skilled assistant should be obtained besides the 
anaesthetist. As regards anaesthetics, it is in our opinion a question to be 
settled for each case ; if the child is so asphyxiated as to be unconscious of 
pain, and not likely to struggle, it is far better to do without an anaesthetic. 
We have seen chloroform prove fatal before the operation was begun ; on 
the other hand, if the case is operated upon earlier, and the child is conscious 
and restless, it is on all grounds better to give chloroform. 

The child then should be placed upon a table of convenient height, and 
the lights, if necessary, arranged carefully. Everything required in the 
operation should be laid out upon a table or chair ready to hand before the 

1 Guy's Reports, ser. iii. vol. vi. 

Z 



338 



Diseases of the Respiratory Apparatus 



child is taken out of bed, since at any moment the moving or the giving of 
the anaesthetic may increase asph) ;ia and demand instant action. 

As soon as the child is unconscious, and not before, since it increase- the 
dyspnoea, one pillow should be taken from beneath the head and placed 
under the shoulders, so that the head falls back and fully exposes the front 
of the neck. Parker recommends a wine bottle wrapped in a towel as a 
neck support. The head must be held by an assistant exactly straight, so 
as to avoid any chance of the operator missing the mid line of the neck. 
The thyroid cartilage is then to be felt for, and an incision, one and a half 
or two inches in length, according to the size of the child, made in the middle 
line from the lower border of the thyroid cartilage downwards nearly to the 




OyiaO-tJiyroid AfeiTibmne 
fc Artery 
_C rie Old CartUa-gi 
SwptTior TAyroul v&tn. 



Anatomy of Child's Trachea. (From ' Gray's Anatomy.') 



top of the sternum. The first incision should be carried through the skin 
and subcutaneous fat ; the second assistant should then draw the edges of 
the wound apart with retractors, and the operator should by successive cuts 
divide the tissues until he reaches the intermuscular septum between the 
sterno-hyoids or lower down between the sterno-thyroids : on reaching this 
he should with a director tear through the line of junction, and the assistant 
should take them up with the retractors. The tracheal fascia will now be ex- 
posed, and should be torn through in like manner, and the trachea bared. 
The tracheal hook is next fixed in the trachea, and drawn slightly forwards 
so as to steady the windpipe and make it prominent ; a short, somewhat 
round-shouldered knife — i.e. one rounded at the back and nearly straight in 
front — is then made to pierce the trachea, and as soon as it has entered 



Diphtheria of the Air Passages 339 

the handle is slightly depressed, and the windpipe is divided from below 
upwards for at least three-quarters of an inch. The knife is now laid 
aside, the dilator passed into the trachea and opened, and the hook re- 
moved ; a free blast of air and the driving" out often of mucus or of mem- 
brane follows. If the trachea is free from membrane, the tracheotomy tube 
fitted with tapes is then passed in between or above the dilator blades, and 
the dilator is removed ; as soon as a blast of air through the tube shows that 
it is in place, the tapes should be tied round the neck, and the operation is 
over. The child should be kept upon the table well wrapped up, with a 
warm sponge over the tube, for a short time to recover itself, and that it may 
be seen that there is no bleeding or other complication ; after a quarter of 
an hour the inner tube may be put in after clearing away all coughed-up 
matter, and the child should be put into its cot and the steam kettle 
arranged. 

Such are. the general outlines of the course of an operation in which there 
have been no complications and no hurry ; it is, however, seldom that such a 
favourable state of things occurs, and it will be convenient to consider more 
in detail the various difficulties that may arise. First, then, one or more large 
veins, inferior thyroid or branches of the anterior jugular, may be met with ; 
if there is no urgency these may be ligatured, either before or immediately 
after division, or forcipressure forceps applied. Should, by any rare chance, 
an artery of any size be wounded, it must of course be treated in the same 
way. In all cases the veins are necessarily intensely congested when dyspnoea 
is marked. In order to avoid danger of wounding veins, some surgeons 
lay aside the knife after the first incision and tear through the tissues down 
to the trachea with dissecting forceps or director. 

Next, the most rigid care must be taken to keep in the middle line : in 
young fat children it is not difficult to miss the trachea, which in them is not 
only small, but so soft as to be readily compressed or pushed aside and so 
missed. Everyone has heard of, if not seen, cases in which the dissection 
has been carried to one side of the trachea, and thus the great vessels &c. 
endangered. In tracheotomy low down, the anterior jugular vein is the vessel 
most likely to be injured. This is, of course, of minor importance. 

The depth of the trachea must also be remembered, and the fact that it 
recedes from the surface towards the lower part of the neck. The deep in- 
cisions must not be carried too close to the sternum, or the innominate vessels 
will be endangered, nor must the trachea be opened so high up as to divide 
the thyroid cartilage and probably injure the vocal cords ; it is well, however, 
to get as low an opening as practicable, in order, if possible, to be clear of 
the obstruction. 

No regard need be paid to the thyroid gland, nor should any attempt be 
made in children to make a ' superior ' or ' inferior ' tracheotomy. In almost 
every case in which the operation has been done examination will show that 
two or three rings of the trachea and the cricoid cartilage, together with, of 
course, the isthmus of the thyroid gland, have been divided — that, in fact, 
a laryngo-tracheotomy has been done, and this is as good as any other 
operation. 

It is not by any means necessary to use a tracheal hook ; if it is not em- 
ployed, the left forefinger should be used as a guide and the trachea steadied 



34-0 Diseases of the Respiratory Apparatus 

by it or between it and the left thumb while the knife is carried upwards by 
the side of the finger or between it and the thumb; in many cases, however, 
the hook does undoubtedly simplify the operation. 

It is of great importance to have the skin wound very free, both to give 
room for the deeper steps of the operation and to prevent the possibility 
of discharge or air being pent up in the cellular tissue of the wound ; no 
stitches should ever be put in. The tracheal opening should be large, 
median, and vertical ; nothing is gained by a small opening, and much trouble 
may arise in inserting the tube. The knife should enter the trachea some- 
what sharply, but not with a stab or plunge which would endanger the 
posterior wall ; cases have been recorded where the knife failed to pierce 
the mucous membrane, and hence the tube was passed into the submucous 
tissue ; in other instances a tough diphtheritic membrane has been pushed 
before the knife and tube — under either condition, of course, no relief was 
obtained by the operation. 

If there is any large collection of membrane or of thick mucus in the 
trachea, the tube should not be inserted at once, but the edges of the tracheal 
wound should be held apart for the child to freely cough out the contents of 
the air passages, and for the surgeon to clear them away and examine the 
surface of the trachea so as to pick off any visible membrane above or below 
the opening. Parker advises the systematic use of the dilator and swabbing 
out the trachea and larynx with a feather dipped in solution of carbonate of 
soda before putting in the tube. Systematic curetting of the trachea has been 
done by some operators. 

The tracheal aperture may be held open either with the dilator or with 
artery forceps, or Golding-Bird's dilator may be worn for a time. 

In inserting the tube it is sometimes difficult to get it into the slitlike 
orifice in the trachea ; under these circumstances the dilator is useful, or if 
one is not at hand, one end of the opening may be depressed by the finger 
so as to make the aperture gape. A bivalve tube is of course the easiest to 
insert for this reason, though it is not by any means the best variety. The 
surgeon should never be satisfied that the trachea is properly opened unless 
free blasts of air are driven out on coughing, nor that the tube is in the wind- 
pipe unless air and mucus are blown out through the tube freely. 

The instrument most commonly used to clear the trachea of membrane 
is a feather ; some of the shorter tail feathers of a pheasant will be found the 
best — if the longer ones are used, the end which is too flexible should be cut 
off. We have had some common brush pipe-cleaners tipped with coralline 
for this purpose, and also a miniature bristle probang made to sweep out the 
trachea. Membrane can often be picked out with forceps. Aspirators of all 
kinds are of use chiefly if not solely for blood and the thinner form of mucus ; 
adherent membrane and thick mucus cannot be drawn out by them ; neither 
is sucking by the mouth any better, hence it is not worth the risk to the 
operator. Anyone who has tried it will know how impossible it is to suck 
out anything except the fluid material, and even for this suction is often un- 
successful. Parker, however, strongly advocates the use of aspirators after 
loosening and softening the membrane by instillation of carbonate of soda. 1 
Where breathing has ceased or is becoming very feeble, artificial respiration 
1 Sodas carbonat. 5ij. glycerine §ij, water to §viij (Parker). 



Diphtheria of the Air Passages 341 

should be performed, and if necessary a catheter may be passed down the 
trachea and the lungs inflated. 1 

Such are the more important points about the operation itself in cases 
where everything can be done deliberately and Trousseau's classical advice, 
1 Operez lentement, tres lentement,' followed. In many cases, however, if 
the operator is slow the child will be dead before the trachea is opened, and 
if not actually dead the almost complete asphyxia will seriously add to the 
dangers of the case. Under such circumstances it is necessary to cut the 
steps of the operation short ; a free incision through the skin, another down 
to the trachea, and the third upwards in the trachea itself. We have often 
had to operate in this way with three cuts, using no instrument except the 
knife and the tracheotomy tube ; after the first two incisions the left fore- 
finger is passed down to the trachea, which is steadied by it ; the opening 
is made and the finger kept as a guide for the tube, which is at once in- 
serted. The finger and thumb may be usefully employed to push back the 
tissues on each side, and, as it were, press forward the trachea. In some 
cases there is free bleeding for a moment or two from the engorged veins ; 
this must be neglected, the tube put in at once, and the child instantly 
turned over on its face to prevent any blood from running into the trachea ; 
as soon as air enters the lungs freely the circulation is re-established and 
the venous bleeding ceases without any treatment. The objection to this 
mode of operating is that it is of course more difficult, and there is some 
risk of blood getting into the air passages ; it is, however, necessary in some 
cases. In very urgent suffocation the operation may even be done in one 
incision through skin and trachea upwards, but this can hardly ever be 
necessary, and has several objections, the chief being that in children the 
trachea can by no means always be felt through the skin, and there is 
great likelihood of emphysema from insufficiency of the superficial wound. - 
Even if the child is apparently dead before the trachea is opened, the 
operation should be rapidly completed, a long feather passed down the 
trachea and withdrawn, and the artificial respiration performed. Recovery 
will often follow even if respiration has ceased for what appears a very long 
time. 

It is well to remember that venous bleeding in tracheotomy is always 
more formidable in appearance than in reality, and always ceases at once 
after the trachea is freely opened. 

Emphysema occurring at the time of the operation is due to too small a 
skin wound or to opening up the cellular tissue in attempts to pass the tube ; 
it may be very extensive and spread down into the thorax ; in such cases it 
is sometimes fatal from pressure upon the lungs. Champneys has shown 
experimentally that there is serious danger of mediastinal emphysema and 
pneumo-thorax when artificial respiration or sudden violent inspiratory effort 
is made after division of the deep cervical fascia ; hence the tube or dilator 
should be put in quickly and the fascia disturbed as little as possible. s 

1 Vide Jennings, Arch. Pcediatr. September 1884. 

2 St. -Germain operates by one incision downwards, beginning by perforating the crico- 
thyroid membrane. Neither this plan nor operation with the thermo-cautery has anything 
to recommend it. 

3 Med.-Chir. Trans. 1882. 



34 2 Pi senses of the Respiratory Apparatus 

A possible danger from entry of air into a wounded vein need only be 
mentioned; instant pressure on the vein and rapid opening of the trachea 

are the remedies. 

Opinions differ greatly as to the best form of tracheotomy tube for 
immediate use. The bivalve is the easiest to insert ; the lobster-tailed tube 
of Durham is open to the objection that it is very difficult to clean ; probably 
Parker's so-called angular tube is the best, and is certainly anatomically the 
most correct ; it has also the advantage of being polished inside. It is, 
however, a matter of little importance what shape of tube is put in for the 
first few hours, provided it is of sufficient size and has a movable shield to 
allow it to lie evenly. The largest size that the trachea will admit should 
always be used to give as much breathing space as possible and to prevent 
play of the tube in the trachea. Parker has shown that the diameter of the 
windpipe is exceedingly variable, and no rules for size in correspondence 
with age can be given. In any case it is advisable to change the tube after 
twenty-four or forty-eight hours, and this gives time for the substitution of a 
Parker's tube for any other that may have been used at the moment. After 
ninety-six hours the metal tube can often be replaced by a Morrant Baker's 

rubber one, or at least a metal tube of differ- 
ent length from that first employed, or, better 
still, the tube may be in favourable cases left 
out altogether. 

As soon as the trachea has been cleaned 
and the child has become quiet after the 
operation, i.e. usually in about half an hour 
or less, the child should be removed to the 
tent, the arrangement of which has been 
already described. 
Fig. 63.— Parker's Tube. The lower part of the wound should be 

dusted over with iodoform, and a piece of 
gauze slipped beneath the shield of the tube to protect the skin and 
wound from it. If the edge of the shield cuts into the wound, the tube 
does not fit well and probably the inner end is pressing upon the tracheal 
wall ; it is either too long in the straight part or the curve is wrong. A 
single layer of gauze wet with 1-40 carbolic or some other antiseptic solution 
should be laid over the mouth of the tube and removed when there is any 
coughing. 

The child must be constantly watched, and at the least sign of dyspnoea 
or any cough the tube should be cleaned with a feather, and coughing 
excited, watching for the moment when mucus appears at the mouth of the 
tube to wipe it away before it is drawn in again. The inner tube should be 
put in as soon as the child has settled down, and taken out every half-hour 
or oftener at first to be cleaned. Special watch must be kept for any sudden 
plugging of the tube by pieces of detached membrane or thick mucus — a 
frequent cause of sudden death after tracheotomy — immediate removal of the 
tube and membrane is required in such circumstances. Abundant discharge 
of thin mucus is a good sign, in so far as there is less likelihood of there 
being any membrane in the trachea if free secretion occurs. 

After-management. — Success in the results of tracheotomy cases depends 




Diphtheria of the Air Passages 343 

more upon after-management than upon anything else, and if surgeons 
could nurse their own cases the mortality after the operation would be much 
less. Constant watchfulness, 7'eadiness to remove the tube altogether and 
clean out the trachea — if membrane continues to form, this should be done 
at least once daily ; the timely administration of stimulants, regulation of 
temperature and moisture are essentials, and can only be satisfactorily seen 
to by the surgeon himself. Cocks [ well insists upon this, and points out 
that sudden obstruction is most often due to inspissated mucus, not to mem- 
brane ; this thick mucus is secreted generally about twenty-four hours after 
the operation, and at the end of three or four days the discharge becomes 
thinner and more puriform (Jennings). 

It is well to feed the child by nutrient enemata for the first few hours, but 
if he is thirsty a few teaspoonfuls of iced milk may be given. During the 
first few days the milk not infrequently comes out in part through the 
tracheotomy tube from imperfect closure of the glottis during deglutition, and 
not, as might be supposed, from any accident to the oesophagus ; on account 
of this occurrence it has been advised to give more solid food by the mouth. 
A certain amount of risk is incurred from this imperfect power of swallowing, 
in that food may pass into the lungs and set up the so-called ' deglutition 
pneumonia:' any such danger may be avoided, as pointed out by Dr. 
Habershon, by feeding the child through a soft catheter ; from 2 to 6 oz. of 
milk may be given in this way every four hours,'- but the plan is rarely 
required. 

If possible the tracheotomy tube should be removed altogether on the 
fourth or fifth day, but this must depend upon how far the disease has sub- 
sided ; if membrane is still coming away, the tube must remain, and it may 
be the eighth or tenth day before it is got rid of. If, as not infrequently 
happens, the dyspnoea returns on closure of the orifice of the tube with the 
finger (always supposing that the tube has a perforation at the bend) or on 
its removal, the difficulty is due to the presence either of membrane or of 
granulation tissue, which may form a polypoid mass springing from the site 
of some patch of membrane, from the edge of the wound, or from an ulcer 
due to the pressure of the tube. Granulation masses, according to Parker, 
are most common about the fourth to the eighth day, and may be expected 
if there are exuberant masses on the margin of the tracheal wound. Morell 
"Mackenzie says they occur from the fifteenth to the thirtieth day, never after 
two months. Parker treats them by the application of nitrate of silver. 
Black patches seen on the outer tube when it is removed are said to indicate 
ulceration at the corresponding spot of the trachea, and should be looked 
upon as an indication for change of the tube to one of different length 
(Parker). Or the dyspnoea may be due to adhesions in the larynx or 
possibly paralysis of the laryngeal muscles, inflammatory softening of the 
trachea, or swelling of the mucous membrane. 

Where, then, the tube cannot be removed entirely after the fifth day, the 
metal one should be replaced by a rubber one, or frequent changes made in 
the length of the tube, and daily attempts made to dispense with the tube 
altogether. Should the obstruction continue, search must be made for its 

1 Archives of Pediatrics y January 1884. 

2 St. Bart/ioiomcw's Reports, 1885. 



344 Pi senses of the Respiratory Apparatus 

cause ; the most common is the granulation mass which may sometimes 
be seen on using the dilator and be removed, its base being touched with 
nitrate of silver. Failing this, it is well to wait a week or so and allow the 
child to regain strength ; it should then be examined under an anaesthetic, 
and, failing the finding of granulations or other obvious cause, a flexible 
probe should be passed up through the glottis from below and a piece of 
silk carrying a small sponge be attached to it ; the probe should then be 
drawn out through the mouth, and the sponge carried through the larynx 
sweeps it out, breaks down any adhesions, and clears away mucus or any 
granulations there may be. We have by this means succeeded in restoring 
the breathing powers after many attempts at doing without the tube for a 
long time. 

The dangers, then, of the too prolonged retention of the tube are the 
possible development of granulation masses and ulceration of the trachea 
which may either lead to haemorrhage from perforating the innominate 
artery or vein, or to subsequent tracheal stenosis from cicatricial stricture. 
Roger, in 1859, and Heilly (Le Progrcs Medical, November 29, 1884), estimated 
that in about one in five of the cases of tracheotomy there is ulceration of the 
trachea, but these results are from ftost-iiiortem observations. The ulcera- 
tion may be either on the anterior or posterior wall of the trachea and gives 
rise to no special symptoms at the time, unless some important vessel is 
opened. 

Sometimes mere nervousness and fear of suffocation prevent the removal 
of the tube ; in such cases attempts must be gradually made by the use of a 
tube with a large fenestra to allow the passage of air through the larynx, while 
the external orifice of the tube is closed with the finger or a cork for gradu- 
ally increased periods of time. Careful watch must always be kept upon 
these cases for fear of sudden asphyxia, which may come on after removal 
of the tube, as soon as the trachea? orifice becomes small, or even later than 
this from growth of granulations from the inner surface of the wound. In 
such cases the wound may require to be reopened and the tube to be inserted 
afresh. In some few cases the tube can never be dispensed with, and has to 
be worn permanently ; but usually some cause of obstruction can be found. 
Sometimes a tough dense cicatricial membrane forms about the lower aper- 
ture of the larynx or upper part of the trachea, and requires removal by 
enlargement of the tracheotomy opening or by thyrotomy. Intubation with 
or without removal of cicatricial tissue is effectual in some cases. 1 In any 
case where the tube has to be long retained, great care must be taken to 
avoid ulceration and to see that the tube is not corroded ; it has several 
times happened that the tube has dropped off the shield and fallen into the 
trachea after long wear. 

As to the application of lotions &c. to the interior of the trachea after 
operation, the number of specifics is as great as that for the throat ; the soda 
lotion and lime water 2 do, no doubt, soften the membrane and mucus, and 
allow it to be more easily detached ; of the other remedies probably the best 
is the instillation of 2 or 3 drops of 1-2000 mercurial solution. The applica- 
tions may be made with a brush or spray producer, or a drop or two may be 
1 Vide Pitts and Brook, Lancet, January 10, 1891. 
- Lime water is soon rendered inefficient by the C0 2 of the expired air. 



Diphtheria of the Air Passages 



345 



instilled through the tube from time to time. Smearing the tube each time 
it is replaced with iodoform ointment is a good plan. The wound should be 
swabbed over daily with a solution of perchloride of mercury (1-2000), and 
then powdered with equal parts of iodoform and boric acid. 

After the operation the child is greatly relieved, usually falls asleep, and all 
goes on well for twenty-four or forty-eight hours, and then in fatal cases death 
occurs, often suddenly. This sudden death may be due to various causes : 
blocking of the tube with detached membrane or mucus, extension downwards 
of the disease, possibly irritation of the vagus (Parker), simple asthenia or 
poisoning by the disease, pneumonia, or cardiac failure. 

There is no doubt that the majority of cases of tracheotomy for diphtheria 
die ; the mortality varies with the epidemic and with the operator, for neces- 
sarily the surgeon who will only operate in the most favourable cases will 
have a lower mortality than he who gives a chance of relief to less hopeful cases 
as well. Hence statistics are of no value. It is, however, roughly true that 
a large proportion of the cases described as croup recover after tracheotomy, 
while those classed as diphtheria mostly die. 

Age has a very important bearing on the success of the operation. 
Children under 2 years comparatively seldom recover ; x the feebleness of 
the child, the increased difficulty of the operation and of the subsequent 
management, all make the prospect at this age worse. R. W. Parker has 
had 50 per cent, of successes in his own practice, but this must be considered 
far better than the average result.'- See also p. 336. 

Archambault, in the Paris Children's Hospital, gives the following table 
of tracheotomy cases : 

years 



3-4 



Cases 


Recoveries 


• 976 


IO4 


. 820 


175 


. 736 


174 


• 497 


I48 


• 547 


I98 



4-5 » 

5-6 „ 

above 6 „ 

Jacobson says one case of recovery in three or four is a good average 
(' Operations of Surgery,' 1897, 3rd Ed.). 

For the general management and feeding of diphtheria cases, as well as 
for the treatment of the fauces and mouth, see Diphtheria. 

Apart from diphtheria or croup, tracheotomy may have to be considered 
in cases of scalds of the glottis, usually the result of an attempt to drink from 
the spout of a tea kettle. In such cases, as Sir S. Wilks has shown, a false 
membrane may be produced exactly like that of diphtheria. 3 The symptoms 
usually come on immediately, and in slight cases soon subside if the child 
is kept in bed in a warm moist atmosphere. Sudden spasm, bronchitis, and 
pneumonia, and the formation of false membrane -are the chief dangers. 

1 But Lindner, Jahrbuchf. Kinderheilk. B. xx. H. 2, records 38 per cent, of successes 
for ' croup and diphtheria,' and most of the successes were in the second year of life ; and 
Chaym, Archiv.f. Kinderheilk. B. iv. H. n, 12, has collected 220 successful cases under 
2 years ; the youngest cases are 6 weeks and 9 weeks respectively ; the latter, however, 
was for post-pharyngeal abscess. — Berliner klin. Woch. 1880. 

2 Edin. Med. Jour. November 1888. 

5 Guy's Reports, 1860, and Bryant in the same number. 



346 Diseases of the Respiratory Apparatus 

The treatment of such cases consists in keeping the child in a tracheotomy 
tent and giving antimony or an emetic. If the child is steadily getting 
worse, tracheotomy should be performed. The tube may be removed 
usually on the third to eighth day. Scarification is often recommended, but 
is more easy to write about than to perform. 

Foreign bodies often find their way into the air passages of children. 
A bead, or grain of maize, or a plum stone, or other foreign body is held 
in the child's mouth, and a sudden inspiration may cause it to pass into the 
larynx. The body may lodge in the upper opening of the larynx or 
in the rima, or may pass into the trachea or either bronchus, usually the 
right. 

Parker records a case in which a caseous lymphatic gland ulcerated its 
way into and blocked the trachea. 1 

If the body is in the larynx there will be dyspnoea and more or less loss of 
voice, with hoarse or ringing cough, and if in the trachea possibly a loose 
rattling sound may be heard on listening over the front of the neck, indicating 
the movement of the body in the trachea. If the substance is lodged in the 
bronchus there will be impaired breath sounds, and possibly collapse of the 
lung on the same side. 

If the history is clear, tracheotomy should at once be performed, as sudden 
asphyxia often comes on quite unexpectedly ; hence urgent symptoms should 
not be waited for. The opening in the trachea should be free, and the edges 
should be held apart to allow of the ready expulsion of the body, which is 
often blown out at once. If this does not occur, the larynx should be searched, 
a probe being passed in from below and the finger made to explore the 
throat from the mouth. If the body is lodged below the opening, the child 
should be inverted and shaken, and if this is unsuccessful an attempt should 
be made to extract the substance with forceps or a brush passed down the 
trachea. Bronchitis and pneumonia usually speedily result if the foreign 
body is not removed. 

Should the attempt at removal fail, if the body is in the larynx and cannot 
be pushed up into the mouth or removed from below, it is probably better 
to follow Holmes's advice and divide partially or wholly the thyroid cartilage 
so as to expose and remove the impacted mass ; the operation is likely to do 
less harm than the retention of the foreign material. If the substance is 
lodged in the lungs, it may possibly be removed at a second attempt or 
may become loosened and coughed up ; occasionally such bodies ulcerate 
their way out and may even reach the surface of the chest. In other cases 
death results from pneumonia or pulmonary abscess. 

Certain other conditions may demand tracheotomy in children — congenital 
syphilitic laryngitis, chronic simple laryngitis, papilloma, or, as already men- 
tioned, pressure of pharyngeal abscesses. 

Intubation of the larynx has been of late years practised by O'Uwyer. 
Waxham, and others, chiefly in America, as a substitute for tracheotomy. It 
has been urged in its favour that it is a less severe measure than that opera- 
tion, and is likely to be permitted by friends when a cutting operation is re- 
fused ; that it does not prevent opening the trachea later, should that become 
necessary, and that it is efficient, while it does not expose a raw surface to 
1 Brit. Med. Jour. October 1, 1890. 



Intubation 347 

the diphtheritic poison nor allow unwarmed air to reach the lungs. A special 
set of instruments is required for this plan. From 20 to 30 per cent. 1 of 
successful results have been obtained, but several drawbacks to its use are 
admitted, such as the difficulty of the manipulation, the liability to displace- 
ment of the tube, and its obstruction by membrane. Our experience of the 
operation has shown that a little practice is required to learn readily to intro- 
duce the tube : it is much more difficult to remove the tube from the larynx. 





Fig. 64. — O'Dwyer's Intubation Apparatus. The figure shows the ' introducer ' with a tube 
fitted on. A separate tube is also shown. 

Several improvements have been made in the apparatus, and the method has 
no doubt a considerable though limited field of usefulness. Intubation, 
as suggested by Symonds, is certainly useful in some cases where after 
tracheotomy there is a difficulty in getting rid of the tube.' 2 

In one instance in which we performed intubation upon a living" child the 
result was disastrous ; a portion of the membrane was pushed down before 
the tube, and the child instantly choked : it was only by immediate tracheo- 
tomy and the use of artificial respiration that breathing was restored. 




Fig. 65. — O'Dwyer's Extractor. The jointed beak fits into the tube and holds it firmly when 
the lever is depressed by the thumb of the operator. 



Others have had similar experience. We have had some experience of the 
method in various forms of laryngeal obstruction, and have not been led to 
take a very favourable view of its suitability for cases of diphtheria where 

1 Vide Waxham, Brit. Med. Jour. September 29, 1888. 

- For further details we must refer to the Medical Chronicle for 1887, where abstracts 
of numerous papers on the subject will be found ; also to the Archives of Pediatrics, 1887, 
and Waxham's paper already referred to, and to the Appendix of the present work ; 
also to Ball's Book on Intubation, and Northrup, Brit. Med. Jour. December 29, 1894. 



348 Diseases of (lie Respiratory Apparatus 

false membrane in any quantity is present. Of eleven cases of intubation 
under our care, in three success followed, in three tracheotomy was 
subsequently successfully performed, and in four instances the children died 
in spite of tracheotomy. The operation appears best adapted for cases 
where there is little or no false membrane — i.e. certain types of acute 
laryngitis, the less severe forms of diphtheria, where tracheotomy is for any 
reason undesirable, and for use in cases where mechanical obstruction 
remains after tracheotomy, or results from cicatricial contraction in the 
larynx. It is certainly unsuitable for bronchitic and pneumonic patients. 
Recently a special pattern of short wide tubes has been used for cases where 
there is much loose membrane or discharge. 1 

Lovett,' 2 from a study of 858 cases operated upon at the Boston City 
Hospital either by tracheotomy or intubation, concludes : 'In general 
I would be glad to advocate the performance of tracheotomy instead of 
intubation in most cases of severe laryngeal diphtheria, except in the cases 
of children under two years, when intubation is to be performed.' 

The apparatus used for intubation, and figured above, consists of a 
special tube with an ' introducer ' and ' extractor.' The child should be 
swathed in a blanket and held upright in the nurse's arms. The mouth is 
held open by a gag, a tube of proper size selected, threaded, and its pilot 
screwed on to the introducer ; the left forefinger passed to the back of the 
throat pulls forward the epiglottis and serves as guide to the tube. Any 
difficulty in introducing the tube may, we have found, be got over by waiting 
for an inspiratory effort on the part of the patient and then slipping in the 
tube : this is a little practical point of much value. As soon as the tube is 
in the larynx the introducer is withdrawn with the pilot, and if the tube is in 
position the thread may be also withdrawn. We are of opinion that it is, 
however, much better to leave the thread in the tube to facilitate extraction ; 
usually it sets up little or no irritation. The tube is then left in position for 
a time varying from a few hours to two or three days, according to the 
circumstances of the case. If left too long it may cause ulceration of the 
larynx or trachea. 3 To remove it an anaesthetic may or may not be given, 
the extractor is introduced into the opening of the tube, which is then with- 
drawn. If too small a tube is used, it may slip into the trachea. Without 
practice the tube is apt to be passed into the oesophagus. 

After the introduction of the tube, relief, though not necessarily imme- 
diate, is usually speedy. There is sometimes difficulty in feeding, from a 
tendency for fluids to pass into the trachea. If this difficulty occurs it can 
be met by feeding the child with its head hanging far back or by giving 
semi-solid food. 

Chronic laryngitis. — Both infants and older children suffer from chronic 
hoarseness, with occasionally acute or subacute exacerbations, with croupy 
symptoms. Such cases may take their origin in a past attack or attacks of 
subacute laryngitis, a certain amount of thickening being left behind. Other 
cases are apparently syphilitic, especially in infants. Tubercular laryngitis 
may also occur, but it is certainly uncommon. The larynx is also sometimes 
affected in cases of chronic pharyngitis where the tonsils are enlarged and 

1 Northrup, Brit. Med. Jour. December 29, 1894. 
2 The Medical News, August 27, 1892. 5 Carr, Lancet, March 28, 1891. 



Papilloma of Larynx 



349 



perhaps post-nasal growths also exist. If the symptoms do not yield to 
astringent applications or the use of caustics such as nitrate of silver, there 
may be so much progressive thickening and dyspnoea that tracheotomy 
may be required ; this is, however, very rarely the case. 

Papilloma of the larynx is a somewhat rare affection, consisting of one 
or more warty outgrowths from the neighbourhood of the true vocal cords. 
The chief symptoms are chronic 
hoarseness, loss of voice, stridulous 
breathing and croupy cough. Later 
there may be intermittent attacks 
of dyspnoea, especially coming on 
at night. There may be loud la- 
ryngeal stridor during inspiration 
and sucking in of the chest walls, 
which is worse at some times than 
others. There may also be loss of 
pulse during inspiration. Where 
laryngoscopy is practicable, in- 
spection shows the warty mass or 
masses usually about the anterior 
part of the glottis. Sudden ob- 
struction of the aperture may result 
from spasm set up by impaction 
of a pendulous growth between the 
cords, or gradual asphyxia may 
come on. A case has been re- 
ported in a child as young as 
14 months ; it is possible these 
growths may be congenital in some 
instances. In a case of our own, 
in a girl of 3^ years there was a his- 
tory of laryngeal stridor from birth. 
Three modes of treatment are 
possible — removal of the growths 
by endolaryngeal operation, a 
method applicable only to late 
childhood and adults ; the second 
is tracheotomy, with or without an 
attempt to remove the growths 
from the tracheotomy wound ; and 
the third is thyrotomy, with ex- 
cision of the warts when fully 
exposed. The last plan, which is the simplest, is open to the objection 
that injury is likely to be done to the vocal cords and permanent aphonia 
may result. Several successful cases by Parker, Davies-Colley, and others, 
have, however, been recorded. On the whole, in this disease, it is probably 
best to perform tracheotomy and trust to spontaneous disappearance of the 
growths, leaving resort to thyrotomy for cases in which long use of the 
tracheotomy tube is unsuccessful. 




Fig. 66. — Papilloma of the larynx. Girl aged 5 
years. The growths are seen attached to the 
vocal cords, and are also present in the neighbour- 
hood of the tracheotomy wound. One or two 
caseous glands are seen at the bifurcation of the 
trachea. See case. (From a photograph by 
F. H. Westmacott.) 



350 Pi senses of the Respiratory Apparatus 

In two cases under treatment at the Children's Hospital by our colleagues 
Dr. Hutton and Mr. Collier, and by ourselves, repeated operations were 
required both in the shape of thyrotomy and of scraping out the growths 
through the laryngeal aperture. The tendency to recurrence was very 
marked indeed, and more than once the windpipe had to be reopened to 
prevent suffocation after the children had appeared to be convalescent. In 
both cases it was found impossible to dispense with a tube. The growths 
sprang from all parts of the interior of the larynx and upper portion of the 
trachea. Hutton 1 points out that cases of spontaneous disappearance of 
these growths have been recorded after portions had been coughed up, as 
well as after tracheotomy without further operation, and after an attack of 
one of the exanthemata. 

Dr. Railton has published two cases in girls aged 3 years and 3 months 
and 4 years respectively who were treated by tracheotomy only. The former 
wore a soft tube for 45 months and the latter 25 months : in both cases the 
warty growths disappeared spontaneously. It must be borne in mind that 
the growths are very apt to form in connection wtih the tracheotomy wound 
on the inner surface of the trachea (see fig. 66). 

The following case unfortunately ended fatally by sudden laryngeal 
obstruction : 

Papilloma op "larynx.— -Mary C, set. 5 years, was admitted into Blackburn Infirmary 
under Dr. Hunt with severe laryngeal obstruction, for which tracheotomy had to be per- 
formed March 1897. She had suffered from attacks of dyspnoea and hoarseness for some 
time before. Several attempts were made subsequently to dispense with the tube, but 
without success. She was admitted to the Children's Hospital November 20, 1897. 
During her stay in hospital, the tube was removed on several occasions and a probe passed 
upwards into the mouth ; the probe passed readily w ithout meeting with any obstruction. 
Examination with laryngoscope was very difficult and without a definite result. The tube 
was removed at first for short intervals, and later removed altogether. She breathed easily 
at night, but at times had attacks of dyspnoea, her voice was hoarse and whispering. Her 
temperature latterly varied from 97°-ioo°, and she lost flesh. She had an attack of urgent 
dyspnoea December 20, 1897, and died suddenly. At the post-mortem, there was early 
tuberculosis at the apex of the right lung and caseous mediastinal glands. There was a 
mass of papillomata on the vocal cords, and also at the site of the tracheotomy wound 
(see fig. 66.) 

In this case it w r as no doubt unwise to remove the tracheotomy tube ; it 
Avould have been better to have allowed her to wear a soft rubber tube for 
many months, or years if necessary, taking care to remove as far as possible 
the warty growths which form inside the trachea at the seat of the tracheo- 
tomy wound. The fact that the girl was suffering from an early stage of 
tuberculosis of the bronchial glands and lung, suggests the possibility of a 
hospital infection with tuberculosis through the tube. Presumably there is 
more risk of this happening to the wearer of a tracheotomy tube, than when 
breathing in the normal way through the mouth and nose. 

1 Hutton, Med. Chron. vol. i. N.s. 1894. 



35' 



CHAPTER XVII 

DISEASES OF THE RESPIRATORY APPARATUS — continued 

Bronchitis and Catarrh 

Catarrh of the bronchial tubes is a common affection at all periods of life 
and in every social grade, but it is in early childhood that it is perhaps the 
most common, and it is at this period that it assumes the greatest importance 
from the diseases which are liable to follow in its train. In old age, when 
the lungs are damaged by emphysema, and the chest walls have lost their 
elasticity, bronchitis is apt to be a serious and often fatal disease ; but not 
less so is it in the very young, in whom the chest walls are alike wanting in 
elasticity and rigidity, the bronchial tubes easily collapse, and the lungs 
very readily join in the inflammation. The greatest liability appears to occur 
during the first two years of life ; certainly at this age it is most fatal. Ex- 
posure to cold is in a large number of cases the exciting cause ; climatic 
influences are seen, especially in late autumn or early winter, in the large 
number of cases of chest affections which occur at this period. That the 
larger number of cases should occur among the lower and worst-housed 
class is only what is to be expected, inasmuch as the lives of the infants and 
children are spent either in the foul and stuffy atmosphere of an overcrowded 
and ill-ventilated house, or they are exposed, imperfectly clad, to all sorts of 
weather in the streets. 

The predisposing causes are many ; some children seem to inherit a 
tendency to bronchial catarrh, and, in spite of the greatest care and the 
most constant ' coddling,' suffer every few months, perhaps for the whole of 
the winter, from bronchial catarrh or severe colds, which pass into bronchitis 
with the greatest readiness ; dentition, rickets, measles, whooping cough, 
intestinal catarrh frequently play an important part in the production of a 
bronchitis. During the time that a tooth is being cut children seem very 
apt to suffer from catarrh, which in the winter affects the bronchial tubes 
and in summer the intestines. Pressure of the tooth on the gums seems to 
act reflexly in producing a catarrh, sometimes with more or less spasm, as 
the child becomes wheezy at night, sibilus being heard all over the chest, 
while in the morning it will be perfectly well. This may happen several 
nights in succession. Rickety children are specially prone to suffer from 
bronchial affections, and in them it is especially serious on account of the 
softness of the ribs, and the weakness of the muscles of respiration, resulting 
in deformed chests and collapsed lung. 

Symptoms and Course. — The attack is often preceded by a cold in the 



352 Diseases of the Respiratory Apparatus 

head, the infant sneezes, its nose runs, and it begins to cough. If the 
bronchial catarrh which follows is mild, and the catarrh does not extend 
beyond the trachea and large bronchi, the general symptoms are slight : 
there is no distress, no dyspnoea, only a troublesome cough, perhaps some 
wheezing during respiration and a slightly elevated temperature at night. 
In the more severe attacks, in which the smaller bronchial tubes are involved, 
their mucous membrane being swollen and the secretion thick and viscid, 
dyspnoea from obstruction to the air entering the lungs will be present. 
The pulse is hard and accelerated, the number of respirations increased 
according to the amount of obstruction, the alae nasi working, the skin 
hot, and the infant restless and thirsty. On placing the ear to the chest, dry 
hissing or snoring sounds will be heard during inspiration, as the air rushes 
through the pulmonary divisions of the bronchi, in the severer cases entirely 
obscuring the respiratory murmur. In the milder attacks rhonchi will only 
be heard with some respiratory movements, being more especially heard at 
the roots of the lungs. 

In infants and young children, especially if their ribs are softened in 
consequence of rickets, there is recession of the chest walls, chiefly at the 
epigastrium and lower lateral region of the chest, due to the imperfect filling 
of the lungs, the chest wall falling in in place of the lungs expanding. In a 
later stage the sibilant or rhonchi al sounds become mixed with moist rales : 
these are not distinctly and sharply crepitant, as of bubbles passing through 
thin fluid, but indistinct bubbling sounds as of air forced through thick 
tenacious mucus. The moist sounds succeeding the dry, point to a freer 
secretion of mucus from the hitherto swollen and congested mucous mem- 
brane. In some cases in infants mucous bubbling rales are heard from the 
first. If convalescence is quickly established, the abnormal sounds are 
gradually replaced by the normal respiratory murmur, though rhonchi or 
rales may be heard for some days or weeks. Percussion of the chest walls 
during an attack of uncomplicated bronchitis shows the resonance normal, 
although perhaps there may be some hyper-resonance at the sub-clavicular 
regions from the presence of more or less emphysema. 

In most attacks of bronchitis there is usually more or less disturbance 
of the digestive organs. The bowels may be confined and distended with 
flatulence, the tongue is coated, and there is often more or less vomiting. 

The fever in uncomplicated cases is never high ; there may be an even- 
ing rise of a degree or two, while the morning temperature may be normal 
or subnormal, especially in weakly children. The cough, which in the early 
stages is hard, in the later stages becomes looser, mucus is coughed up into 
the pharynx and then quickly swallowed, unless extracted by means of 
the nurse's finger. Children under five years rarely expectorate — mucus is 
coughed up, but they have not the sense to spit it out. 

An attack of bronchitis usually lasts a week or ten days and ends in 
recovery, leaving the child subject to a second attack. 

Complications. — Bronchitis in infants and young children is frequently 
accompanied by one or more complications, the commonest being collapse 
of the lung, catarrhal pneumonia, bronchiectasis, and emphysema. In a fatal 
case it is almost certain that one, or more often all four, of these complications 
will be found. 



Bronchitis and Catarrh 353 

Collapse of Lung;. — During an attack of bronchitis or bronchial catarrh 
it is not uncommon to note that the respiratory murmur is weak or absent 
over a portion of lung — as, for instance, one or other base ; then perhaps after 
a vigorous cough a plug of mucus is dislodged from a large bronchus and 
the breath sounds, with perhaps some loose rales, are heard over the same 
area. At other times the breath sounds are absent, and by the next day the 
ordinary respiratory murmur will again be heard. In this case a plug of 
thick mucus lodged in one of the larger divisions of the pulmonary bronchi 
prevents the ingress and egress of the air from the lung, but is expelled 
and coughed up by an extra effort. 

If, however, thick mucus is drawn into the smaller bronchi, perhaps 
filling up a series of small branches, the most powerful expiratory effort the 
child can make fails to clear the occluded bronchi, especially when the re- 
spiratory muscles are weak and the ribs are soft and easily bend. Two 
things are now certain to happen — the lung supplied by the occluded bronchi 
collapses and more or less dilatation of the bronchial tubes and emphysema 
of the neighbouring lung occurs, unless the chest walls fall in to take the 
room of the collapsed lung. The lung collapses in consequence of the 
absorption of the imprisoned air, the air entering the blood-vessels, as shown 
by the experiments of Lichtheim. It is clear that this collapse of lung and 
vicarious emphysema at least temporarily damages the lung, and if this 
' should occur to any great extent in acute bronchitis, it adds considerably to 
the danger of death by asphyxia. 

The symptoms to which collapse gives rise are not always very definite, 
and unless tolerably extensive there may be no sign of its presence. In 
some cases it may supervene suddenly, possibly by the sucking" in of mucus 
which has accumulated in the trachea during sleep into the bronchial tubes, 
the dyspnoea becoming urgent, the child's lips blue ; it rolls about in its cot 
struggling for breath, and convulsions come on which perhaps prove fatal. 
In other cases, while the symptoms may be alarming for the time, they 
quickly pass away, a result due to the mucus being expelled. If the collapse 
is scattered in patches throughout the lung, especially if accompanied by 
emphysema, it will be impossible to detect it by any physical signs : there 
may be hyper-resonance due to the emphysema, weak breath sounds, and 
perhaps some moist rales. If any extent of lung is involved, as part of an 
apex or base, there will be some loss of resonance, but this is rarely well 
marked unless some broncho-pneumonia be associated with it, a pneumonic 
patch and a collapsed patch lying side by side. The respiratory murmur 
over the collapsed patch is weak, and rhonchus or moist sounds may be 
heard. In some cases there appears to be a mixed condition of collapse 
with much congestion of the vessels and cedema, or possibly, as some authors 
believe, the collapsed lung becomes the seat of a low form of pneumonia, 
leucocytes and epithelioid cells being present in the air sacs. 

Bronchiectasis and Emphysema. — Dilatation of the bronchi frequently 
takes place during acute bronchitis, the walls of the medium-sized and small 
bronchi being thin and their calibre increased, a result no doubt due to in- 
flammatory softening of their walls. Emphysema is also constantly present 
in association with dilated bronchial tubes. The chest walls during an acute 
attack assume the position of inspiration, and, particularly the infraclavicular 

A A 



354 Diseases of the Respiratory Apparatus 

regions, become hyper-resonant, while the expiratory murmur is prolonged. 

As aheach- remarked, compensatory emphysema is constantly present in 
association with broncho-pneumonia and collapse. Bronchiectasis takes place 
in association with chronic pleurisy and fibroid conditions of lung. 

Chronic Bronchitis and Bronchiectasis 

Children and infants, like adults, suffer from chronic bronchial catarrh ; 
they recover slowly, and then perhaps within a few weeks another attack 
supervenes. Some children show such a tendency to these attacks that they 
have to be kept prisoners almost all the winter, as exposure to even slight 
cold is sufficient to lay them by for weeks. Frequent and long-continued 



IlllllllliillliiSIllllllilli 




sillasHHsmsfiiftl&iSisi'a^BB 

5SS3SB BBBSUSSSSiSITaSSffiSBB 

SBBSa SSB j 




Si'iS! 



IBMgiHIIIlEIIlHiliii 





Fig. 67. — Temperature Chart of a case of Bronchitis with disseminated patches of Pneumonia. 

Boy of 5 years. Recovery. 

attacks of bronchitis are certain sooner or later to produce emphysema, 
dilated bronchial tubes, and dilatation of the right side of the heart and the 
veins which empty into it. Such children present a typical picture ; they 
are mostly thin, with rounded drooping shoulders, barrel-shaped chests, 
enlarged superficial jugular veins and often injected capillaries on the cheeks 
In some of these more or less dulness may be detected at one base or another, 
and they constantly cough up large quantities of very foul mucus. Such cases 
are anything but welcome inmates in a ward on account of their extremely 
foetid expectoration. They are very chronic and not much amenable to 
treatment. We have attempted external drainage of the dilated bronchial 
tube, but have not met with much success, as the patient gradually sank. 
In the milder cases such children with care improve greatly, and frequently 



Clironic BroncJiitis — Broncho-pneumonia 355 

by puberty lose their tendency to bronchial troubles, and grow up, if not 
strong, at least not with impaired health. On the other hand, there is always 
the risk of an intercurrent and perhaps fatal pneumonia ; we have seen 
children of this class with marked emphysema come regularly into hospital 
perhaps twice in a winter with attacks of croupous pneumonia. There is a 
risk of chronic bronchitis passing into a chronic broncho-pneumonia, the 
lung tissue around the dilated bronchi becoming fibroid and indurated. 
There is also the risk of tuberculosis, but we have not often been able to 
trace a connection between chronic bronchitis and tuberculosis, though those 
suffering from chronic bronchitis are often mistaken for phthisical subjects. 

Broncho-pneumonia 

In many cases the attack begins with a bronchial catarrh and quickly 
passes on into a broncho-pneumonia, the inflammation extending from the 
bronchi into the air-cells. In other cases the bronchial symptoms may be 
slight or absent, and the attack may closely resemble a croupous pneumonia. 
Between these two types all gradations may be met with. When the pneu- 
monia supervenes on bronchitis, all the symptoms become exaggerated, the 
child is restless, the cough shorter and more hacking, the skin hot and dry, 
the evening temperature usually reaching 103 or 104 with morning remis- 
sions of several degrees, so that the fever assumes a remittent type ; sometimes 
there are evening instead of morning remissions, the temperature being at 
its lowest in the evening ; the dyspncea is usually great, the respirations 
numbering forty or fifty, but varying with the amount of fever and extent of 
lung involved. If the pneumonia is extensive, the face wears a distressed 
expression, the alas nasi work vigorously, the child lies weak and helpless in 
its mother's arms, too feeble to cry, or if it resists examination for a while it 
is soon exhausted and passively submits. 

An examination of the chest, if made when the attack is fully developed 
and severe, shows that the accessory muscles of respiration are brought into 
play, the respirations are rapid and shallow, with recession of the epigastrium 
and intercostal spaces. The percussion note varies according to the position 
of the consolidated lung ; this may involve an extended portion at one or 
both bases, at an apex, or be scattered in patches over the lungs. To detect 
the pneumonic portions both light and strong percussion should be practised, 
carefully comparing any spot where the resonance appears impaired with 
the opposite side. There may be hyper-resonance, especially anteriorly, 
from the presence of emphysema. A considerable amount of pneumonia 
may exist if diffuse or patchy without any definitely impaired resonance. 
There is never complete dulness in pneumonic consolidation unless much 
lymph or some fluid be present. On auscultation rhonchi are usually heard 
over the chest, while over the pneumonic portions rales of a consonant or 
ringing character are heard, which contrast with the subcrepitant rales of 
a simple bronchitis, inasmuch as they are more intense, from the fact of 
their travelling to the ear through consolidated lung. Even though no 
consolidated lung can be detected by percussion, the presence of consonant 
intensely ringing rales with a temperature of 103 or 104 points almost cer- 
tainly to pneumonia. 



356 



Diseases of the Respiratory Apparatus 



In the early stages the respiratory murmur is weak, later there is mostly 
well-marked bronchial breathing" over the dull area. If a fatal result is 
about to occur, the respirations become more hurried, the distress greater, 
and the pulse weaker and weaker ; rales and rhonchus are heard over the 
whole chest, the heart flags, and the child becomes pallid and comatose, 
death taking place with symptoms of toxaemia on account of the bronchi 
becoming choked and the lungs consolidated. The temperature usually 
falls towards the close ; the child is frequently convulsed. If, however, the 
attack takes a favourable turn, towards the end of the first week or earlier 
the temperature approaches normal, the breathing is easier, and the child, 



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iiiipiiffiliHimSi 

■■■■ wMHiHiuHBiffia an 

W&m !S«s«!?JS!w±ih mm 




Fig. 68. — Temperature Chart of a case of acute Broncho-pneumonia in a boy of 2i years; 
death fifteenth day. At the ftost-mo7-tem both bases of lungs showed generalised broncho- 
pneumonia with ' graines jaunes.' 

instead of concentrating his whole attention on himself, begins to notice 
those about and to play with his toys. The physical signs change but 
slowly, the bronchial breathing and rales being heard perhaps during the 
second or even the third week. 

While the above is the description of a typical attack, the pneumonia 
may be of much less well-marked character. The child may seem ill with 
little or no cough, while there is loss of appetite, coated tongue, and feverish- 
ness, especially well marked during the afternoon or evening. An examina- 
tion of the chest may at first yield no positive result, yet in a.day it will be 
noted that there is a patch of lung at the extreme base, axilla, or near 
the root where the air does not enter well, and the respiratory murmur is 



Broncho -pneumonia 



357 

In a few days or a 



replaced by breathing of a distinctly bronchial character, 
week the temperature may again become normal. 

Sometimes an attack of broncho-pneumonia closely simulates the 
croupous variety, and there may be a doubt as to which category to refer it. 
The onset may be sudden, accompanied by a convulsion or series of convul- 
sions, the temperature may rise to 104 or 105 (see fig. 69), the physical 
signs may point to an extended portion of lung being involved, and only the 
course of the attack, the temperature 
becoming intermittent, and reaching 
normal gradually by lysis, would seem 
to indicate that the attack is rather 
of the catarrhal than the croupous 
variety. Some cases may from first 
to last be open to doubt. 

Course. — Whilebroncho-pneumonia 
is frequently an acute disease, proving 
fatal in a few days or a week, its course 
in many cases is subacute or chronic, 
lasting for several weeks, or even 
more, and yet ending in apparently 
complete recovery. In some instances 
recovery takes place, to be followed 
by a relapse, the temperature again 
becoming remittent for a few days or 
a week. The termination of the fever 
is nearly always by lysis. In these 
protracted cases the possibility of tu- 
berculosis or a local empyema must 
always be borne in mind. 

Secondary Pneumonias. — Pneu- 
monias, mostly of the broncho-pneu- 
monic form, occur as complications of 
many diseases, and may in consequence 
be modified in their course and in 
the symptoms they present. Thus a 
miliary tuberculosis may give rise 
to an acute broncho-pneumonia, which 
may run a short or protracted course, 
the two conditions present essentially 
modifying each other. In whooping: 
cough, measles, scarlet fever, diph- 
theria, enteric fever, pneumonia may supervene, caused by the specific 
micro-organism of the fever, or, in many cases at least, by the septic organisms 
present. While the pneumonia occurring in these diseases is usually of the 
broncho-pneumonic form, yet it is mostly fibrinous, and in the worst cases 
exhibits a tendency to pus formations, so that small purulent abscesses may 
be found post mortem. In some cases a true croupous pneumonia may 
occur. In diphtheria the pneumonia is often haemorrhagic, small patches 
of dark red extravasated blood being seen on section of the pneumonic lung. 




Fig. 69. — Temperature Chart ot a case of acute 
lobar Pneumonia in an infant of 9 months ; 
death on third day. The whole left lung 
except a small part of upper lobe, which was 
emphysematous, was solid ; section of lung 
not so solid as red hepatisation ; lobules dis- 
tinct, some of a pink and others of a greyish 
colour. 



358 Diseases of the Respiratory Apparatus 

In acute summer diarrhoea a pneumonia is very apt to be present and 
add to the gravity of the attack ; in the chronic intestinal catarrh of 

infants the immediate cause of death is frequently an intercurrent attack of 
inflammation of the lungs. 

Chronic Broncho-pneumonia. — Attacks of broncho-pneumonia are apt 
to become chronic in consequence of an imperfect clearing up of the lung 
and the resulting caseous degeneration. Catarrhal pneumonia following 
measles or whooping cough is very apt in an unhealthy child or one who 
inherits tubercular tendencies to take a subacute course ; a base, or, less 
often, an apex of a lung remains more or less dull, the breath sounds are 
bronchial, moist sounds are heard, and the evening temperature rises to 102 
or 103 F., with night sweats and emaciation. This state of things may go on 
for weeks, and it may be impossible to say if the caseous changes are pro- 
gressing or not. The risk in such cases is undoubtedly that, although the lung 
may clear up, the bronchial glands may become caseous, and a general tuber- 
culosis of the lung, or perhaps tubercular meningitis, follow. Most cases of 
chronic broncho-pneumonia terminate either in recovery or tuberculosis, 
though in some instances they run a very chronic course, resembling a chronic 
phthisis ; the bronchi become dilated, caseous and fibroid changes occur, 
but rarely acute tuberculosis. Such cases during life are mostly regarded 
as chronic or fibroid phthisis : they present in their later stages the signs 
of consolidation of a portion of lung at an apex or base, the chest wall is 
probably retracted, there are bronchial breathing, sharp ringing rales, 
and very foetid expectoration, which is coughed up in large quantities. 
They are thin, anaemic, are easily put out of breath, have clubbed fingers and 
dilated right hearts. They are usually very chronic cases. At the post- 
mortem there are found dilated bronchi filled with thick, foul secretion, 
cheesy nodules around the bronchial tubes, much fibroid and indurated 
lung tissue, and emphysema. In some cases there is gangrene of the lung 
before death. Children liable to bronchitis, or who suffer from it in the chronic 
form, require to be warmly clothed and protected from cold. Residence in a 
warm climate and pure atmosphere during the winter, and at high altitudes 
during the summer, should be insisted on where possible. A warm house 
is necessary if they have to winter in this climate. Every means must be 
employed which will improve their general health. In the following case a 
chronic pneumonia was followed by acute meningitis. 

Chronic Pneumonia. Acute Meningitis.- — RoseS., aged 5 years. Child comes of a 
tubercular family ; has had acute pneumonia several times. She had acute pneumonia 
several weeks before admission, and was sent to the seaside. Admitted July 7. There 
is dulness on the left side behind, extending from the spine of the scapula to the base ; 
over this area there is weak bronchial breathing, and what is apparently redux crepitation. 
Temperature 101 . Xo albumen ; child well nourished, but pale. Temperature fell to 
normal during the next day or two. On July 15 the temperature suddenly rose to 104° F. 
Towards evening she began to vomit continuously ; temperature rose to 105 F. ; there 
were some preliminary twitchings, and then she was severely convulsed. The convulsions 
continued till early the next morning, when she died. 

Post-mortem. — Left lobe solid ; sinks in water ; bronchi contain much purulent secre- 
tion, and their walls are thickened ; excess of fibrous tissue in the lung, spreading from 
the root. Lung substance dark red, soft, and contains some small cavities size of peas, 
containing thick, almost cheesy, pus. Xo obvious tubercle anywhere. Brain, arachnoid 



BroncJio-pneiunonia 359 

everywhere cloudy, beneath it there is an excess of fluid of a cloudy yellow tint. 
Sylvian fissures are matted with semi-purulent lymph. Base of brain much cloudy, 
swelling beneath arachnoid. No tubercle anywhere. 

Prognosis. — Broncho-pneumonia is always a dangerous disease, but more 
especially so in children under 2 years of age who are rickety or weakly. 
The prognosis is necessarily serious if the pneumonia follow any other dis- 
ease, as measles, whooping cough, or summer diarrhoea, or when it occurs in 
scarlet fever through the extension of the inflammatory process in the throat. 
In any severe case the danger depends upon the amount of lung involved 
and the softness of the chest walls. It must also be remembered that a young 
child may struggle through the bronchial affection only to pass into a con- 
dition of atrophy — the result of a gastro-intestinal catarrh. Both high and 
also very low temperatures are indicative of danger. The pneumonia may 
become chronic and tuberculosis supervene. 

Morbid Anatomy. — The appearances seen post mortem in the bodies of 
children dying of bronchitis and broncho-pneumonia are very various, and 
are apt to puzzle those unaccustomed to the autopsies made in children : and 
much confusion has existed in the past in reference to them, especially in 
confounding the various forms of pneumonia and carnification of the lung 
with collapse. Collapse of the lung is mostly patchy in its distribution, rarely 
affecting any continuous extent of lung or involving the whole thickness of a 
lung. It affects the anterior and inferior edges of the lungs, especially the 
anterior edge of the middle lobe of the right side and tongue of the left 
which covers the heart ; it is sometimes present along the posterior border of 
the lung ; the collapsed portions are depressed below the surface, purple in 
colour, and airless. Taken between the finger and thumb, there is no sub- 
stance to be felt as in pneumonia. The collapsed portions can be inflated 
through the bronchi. The collapse is brought about in at least two ways — 
either from occlusion of a small bronchus by thick mucus, the air being first 
imprisoned and then absorbed by* the capillaries, or by feeble inspiratory 
power aided by obstruction to the entrance of air, especially w T hen the ribs 
are soft, as in rickets ; in this case the chest falls in during inspiration, in- 
stead of the lungs becoming distended ; it is in this way that collapse is pro- 
duced along the anterior edges of the lung. The collapsed portions become 
cedematous from the stagnation of the circulation ; according to some, they 
become pneumonic. 

What happens to the collapsed portions of lung in the long run is not 
clear. In most cases, apparently, recovery takes place ; but we believe in 
some cases fibroid changes are set up, as evidenced by those chronic cases of 
bronchitis and dilated tubes, the latter surrounded by indurated lung. Acute 
emphysema plays an important part in the acute lung disease of children. 
It is sometimes produced very rapidly ; thus, a child may die of acute broncho- 
pneumonia complicating measles in three or four days, and extensive emphy- 
sema may be present, no doubt produced during the period, and contributing 
very materially to the fatal result (see p. 353). The bases of the lungs are 
in an early stage of pneumonia and collapse, the upper lobes are overworked, 
the constant coughing consequent on the acute bronchitis produces emphy- 
sema, and the only remaining normal lung is thus damaged, and a fatal result 
quickly ensues. 



360 Diseases of the Respiratory Apparatus 

The chief types found may be described shortly in the following groups : 

1. Acute Bronchitis involving the Smaller Tubes, Collapse of Lung, 
Vicarious Emphysema. — On opening the chest the lungs are found to be in 
a condition of deep inspiration ; these surfaces are studded over with clusters 
of lobules which are depressed and purple in colour (collapse), and with 
raised portions which are of a pale pink colour (emphysema). On section, 
thick semi-purulent frothy mucus exudes from the large and small bronchi ; 
the latter sometimes contain a semi-membranous exudation. The cut surface 
of the lung exudes much blood-stained frothy fluid, due to congestion of the 
lung ; the lungs are crepitant, except where collapse has taken place. The 
large veins and right heart are much engorged. 

2. Disseminated Broncho-pneumonia. — The bronchial tubes contain 
much frothy fluid, one or both lungs, especially the lower lobes posteriorly, 
have a semi-solid feel, but crepitate, and perhaps some nodules of various 
sizes may be felt. The section exudes much serum, purulent mucus exudes 
from the small bronchi, the cut surface of the lung has a mottled appearance, 
caused by clusters of lobules, which are grey or pale pink and have a firm 
feel, and bright red portions of crepitant lung. The paler portions are pneu- 
monic and solid ; the red portions are air-containing congested lung, which 
surround the pneumonic portions. Portions of lung which are removed will 
float in water, but easily break down on thrusting in the finger. The upper 
lobes are emphysematous. 

3. Acute Generalised Broncho-pneumonia, Pleurisy. — The posterior 
inferior or whole of one or both lobes has a semi-solid feel, though less solid 
than in croupous pneumonia, with but little or no sense of crepitation. The 
surface is purplish in colour ; the pleural covering may have minute haemor- 
rhages on its surface, or be roughened from the presence of lymph. The cut 
section has a solid feel, yet it is not granular as in true croupous pneumonia, 
but easily breaks down on pressure with the finger, and sinks in water. It 
has a mottled appearance, in consequence of the lobules surrounding the 
terminal bronchi being paler in colour and in a later stage of consolidation 
than the intervening portions of lung. There will probably be collapse 
of the anterior and inferior edges, as well as acute emphysema in the 
same positions ; some of the vesicles are frequently distended to the size of 
millet seeds, or even peas, and perhaps one here and there is ruptured. In 
a still later stage, especially if the inflammation is intense, as in measles or 
scarlet fever, a lobe may be solid, and on the surface beneath the pleura 
there are a number of yellow spots, the size of millet seeds or larger, which 
on pricking yield a drop of thick pus. On section, these yellow spots are seen 
scattered through the lung ; they are the ' graines jaunes,' or ' abces peri- 
bronchique,' of French authors, and are, in fact, minute abscesses surrounding 
the terminal bronchioles, formed by the softening of the pneumonic lobules. 
Pleurisy with lymph or serum may be present ; when the pneumonia is double 
the temperature usually runs high. 

The following case illustrates this form of pneumonia : 

Acute Double Pleuro-pneumonia, Hyperpyrexia, Suspicion of Meningitis. — John H., 
aged 14 months ; admitted April 26, 1894. His mother states he has been a healthy child 
up to the present illness. A fortnight ago he became ill with cough and fever. Breathing 
has been very bad at nights. He vomits frequently. He is fairly well nourished ; his 



Broncho-pneumonia 361 

head is somewhat retracted, and muscles of the neck are rigid. The right apex in front 
and the base behind are very dull ; bronchial breathing and sharp crepitation are heard over 
this area. On the left side there are rales, but no dulness ; §ij of clear serum were with- 
drawn from the right side behind. Temperature 103 . Vomits constantly. April 27.— 
General convulsions, mostly right-sided ; marked rigidity of the neck ; vomits constantly. 
Well-marked tache cirdbrale. April 28.— Very short breathing ; dulness well marked at 
the left base as well as the right. Oxygen given. Temperature 106 . Graduated bath. 
April 29. — Marked retraction of the neck ; constant vomiting. Temperature 106-4°. 
April 29. —Temperature 106-4° twice during the day. Death May 1. 

Post-mortem. — Right pleural cavity contains §j of yellow serum, and lymph covering 
the lower lobe, which is partly compressed and partly solid ; upper lobe solid at the back, 
showing broncho-pneumonia and emphysema in front ; lower lobe, lymph on surface, 
pneumonia on section. Much clear fluid escaped from surface of the brain and lateral 
ventricles ; no lymph anywhere. Arachnoid cloudy ; veins full. It was suggested that 
the infant had meningitis complicating the pneumonia, but this was not borne out by the 
autopsy. 

4. In infants under 6 months a form of pneumonia is sometimes 
found which does not agree with the above description. A lobe, generally 
one of the lower, is semi-solid, its surface depressed and purple, surrounded, 
perhaps, by raised emphysematous vesicles. The cut section is smooth and 
of a uniform plum colour, the lobules indistinct and airless, but the lung has 
not the solid feel of red hepatisation. 

5. In some cases nodules of fibrinous pneumonia as large as hazel nuts 
or walnuts, hard, and with a granular surface, may be found. We have seen 
this condition in connection with measles. 

It has already been remarked that clinically broncho-pneumonia some- 
times so closely simulates croupous pneumonia that it is difficult to say to 
which variety it is to be referred. The same difficulty may occur in the 
post-moriem room, as some lobular pneumonias have almost the solid feel 
found in croupous pneumonia, and a microscopic examination shows the 
air vesicles to contain fibrin, and yet the section, to the naked eye, is not 
granular as it is in red hepatisation, but mottled, the clusters of lobules 
varying in tint, and more closely resembling in appearance the condition of 
broncho-pneumonia. 

The micro-organisms present in the broncho-pneumonia occurring 
in children have been studied by recent observers, more especially by 
Neumann, 1 Queisner, 2 Strelitz, 3 and Prudden and Northrup. The commonest 
micro-organism found appears to be the Frankel-Weichselbaum diplococcus, 
much less often Friedlander's bacillus. In the septic pneumonias present 
in scarlet fever, measles, and diphtheria various micrococci — including 
Staphylococcus pyogenes aureus and albus, and Streptococcus Pyogenes — are 
usually present. In the present state of our knowledge it is unwise to lay too 
much stress on the presence of these organisms in the pneumonic lungs ; but 
it seems exceedingly probable that there are several micro-organisms which, 
if the conditions are favourable, are capable of giving rise to inflammation of 
the lungs. 

Diagnosis. — A clinical distinction between the above conditions is often 
impossible, inasmuch as bronchitis, collapse, emphysema, and catarrhal 

1 Jahrbuch Kinderh. Band xxx. p. 233. 2 Loc. cit. Band xxx. p. 277 

3 Archiv f. Kinderh. Band xiii. p. 468. 



362 Diseases of the Respiratory Apparatus 

pneumonia may all exist in the same lung, and more or less mask one 
another. However, a few points may be emphasised. In simple bronchitis 
the temperature is rarely high, there is no impairment of resonance, and the 
moist sounds, if present, are indistinct and distant. In broncho-pneumonia 
the temperature is higher, usually there is impaired resonance, perhaps 
whiffy or bronchial breathing, and the moist sounds are clear, sharp, and 
ringing. The diagnosis of collapse is much more uncertain unless much 
lung is involved ; then there are impaired resonance and weak and distant 
bronchial sounds. 

In all cases of broncho-pneumonia we must bear in mind the possibility 
of some localised collection of pus being present over a dull patch, and also 
that the case may be one of miliary tubercle as well as broncho-pneumonia. 

TreatDieiit. — The colds in the head and bronchial catarrhs of children 
call rather for careful hygiene than active treatment. Confinement to a well- 
-armed and ventilated room or suite of rooms, as long as the symptoms of 
a cold are present or rhonchi are heard in the chest, with a light, mostly fluid 
diet, will in many cases be all that is necessary. Merely to confine a child 
to the house and let it run about in cold passages and stand in draughts is 
useless, and likely to give rise to another cold before the first has completely 
passed away. Some children are exceedingly liable to take cold, and bron- 
chitis follows very readily, and with these extra care must be taken, and the 
last trace of a cold must have disappeared before they are permitted to go 
out. In those cases where there is a laryngeal or tracheal catarrh the cough is 
often troublesome, especially keeping the patient awake at night and disturb- 
ing the whole household. Among the household remedies for coughs which 
are useful are black currant jelly, glycerine lozenges, liquorice, and jujubes 
simple or medicated. A cup of hot beef tea or cocoa the last thing at night 
will often soothe a troublesome cough. In many cases it will be necessary 
to give small doses of some sedative, especially in the case of older children. 
Morphia, codeia, aconite, hyoscyamus, bromide of ammonium, may be given 
for this purpose, made up in the form of a linctus with syrup of orange or 
tolu or glycerine. The morphia and ipecacuanha lozenges of the B.P. made 
with fruit paste or glycerine jelly are very convenient. Codeia jelly acts 
exceedingly well in soothing irritable coughs. 

The diet should consist largely of fluids, milk, beef tea, light puddings. 
Lemonade, barley water, linseed tea, to assuage thirst and tend to produce 
free action of the kidneys and skin, are likely to be useful ; salines such as 
citrate of ammonia or potash, or liq. ammon. acet., may also be given. 

The prevention of attacks of bronchial catarrh and colds is a matter of 
much importance, especially in the case of those who are liable to bronchitis 
or asthmatic attacks whenever they take cold. A house in a dry and bracing- 
situation, with well-warmed living rooms, passages, and bedrooms — while 
the ventilation and sanitation are carefully looked after — is a first necessity 
in the prevention of colds. Care must be taken that such children are 
properly clothed with well-fitting woollen under-garments, that they have 
plenty of exercise in the open air whenever the weather is suitable, while cold 
sponging or the tepid douche in the morning whilst standing in warm water is 
of much service in promoting the circulation in the skin and preventing chills. 

Are ' colds in the head ' infectious ? It is a common experience that 



Broncho-pneumonia 363 

almost a whole household is affected at the same time or in succession, and 
there can be little doubt that in some cases a nasal catarrh passes from one 
child to another without the latter having been exposed to any chill. Other 
conditions favouring these attacks may be present, but of these next to 
nothing is known. Possibly a chill may predispose the mucous membrane 
to take on inflammation or become a suitable nidus for the cultivation of 
bacilli or other organisms present in the atmosphere. 

If the catarrh passes downwards from the trachea into the smaller tubes, 
and the child in consequence ' wheezes ; and rhonchi are heard all over the 
chest, the child should be confined to its bed or cot, care being taken to have 
it warmly clothed and in a situation free from draughts. In the more severe 
cases of bronchitis and catarrhal pneumonia, especially in small children, a 
sort of tent should be rigged over the cot, or one or two clothes screens placed 
around with sheets hung on them so as to form sides and a roof will answer 
very well. The atmosphere must be kept moist by means of a bronchitis 
kettle, or the sheets which form the walls of the tent may be kept moist. 
The temperature in the cot should be maintained at 65°-7o° night and 
day. The diet should consist entirely of fluids if the attack is at all acute. 
Milk diluted with one-third or one-fourth part of whey, barley water, or soda 
water should form the principal kind of nourishment ; a cup of beef tea 
once or twice a day may be allowed. Moist, hot applications to the chest 
are soothing to the patient, and may be applied in the form of linseed poultices 
or fomentations. It must, however, be borne in mind that poultices made by 
unskilled hands may, especially in the case of infants and young children, 
do more harm than good ; to surround the chest of an infant with a heavy 
poultice when the bronchial tubes are choked with thick mucus and patches 
of lung are in a state of collapse is simply to invite death by suffocation. The 
poultices should be well mixed, being not too heavy nor applied too hot 
(placing them against one's cheek is the best guide), carefully kept in position 
by means of a flannel binder, and renewed at least every four hours. A 
mustard poultice is often of great service in the early stage ; one tablespoonful 
of mustard to four or five tablespoonful s of linseed meal may be used, the 
poultice remaining on for three or four hours. This strength is not sufficient to 
produce more than some redness, and it can be renewed or replaced by a 
simple poultice according to circumstances. For infants and young children 
hot fomentations applied by means of spongio-pilinejor flannel are preferable 
to poultices : they are much more cleanly, and harm is less likely to be done 
by their application. Several layers of flannel may be used wrung out of 
water, or if need be mustard and water, and covered with a piece of oiled 
silk, the whole being surrounded by cotton wool. Poultices and hot applica- 
tions are of most service in the early stages, when the mucous membrane is 
swollen and dry, and the secretion scanty ; in the later stages they are also 
useful if the secretion is thick and coughed up with difficulty. 

In the early stage of bronchitis, if there is much wheezing, dyspnoea, and 
distress, an emetic is of much service, more so, perhaps, in bronchitis than in 
catarrhal pneumonia. Pulv. ipecac, in 5 -grain doses in syrup of orange 
peel may be given to a child under 2 years of age and repeated in a few 
minutes if it fail to act. The act of vomiting, especially after ipecacuanha, 
will probably be attended by a freer secretion of mucus and relief to the 



364 Diseases of the Respiratory Apparatus 

breathing. At this period the depressant expectorants which appear to 
diminish tension in the vessels, and thus relieve the congested mucous 
membrane are mostly used. Of these antimony, ipecac, and aconite are 
more frequently used than any others. In this stage, when the cough is 
hard and sibilus is heard in the chest, antimony in small repeated doses, 
short of producing nausea and depression, is of much service. (F. 46.) 

In catarrhal pneumonia aconite in half-minim or minim doses is preferable. 
The drug may be continued for several days, as long as the fever lasts or 
the secretion remains scanty or is coughed up with difficulty. Given with 
caution and in small doses there is little fear of its producing too great de- 
pression ; in feeble children, however, it may be well to give small doses of 
alcohol at the same time. Many prefer to give ipecac, or, instead of aconite, 
antimony, especially in the feeble and cachectic patients so often met with 
in the out-patient room. Some believe ipecac, combined with alkalies such 
as bicarbonate of potash to be of especial value when mucous rales are heard 
in the chest, and the infant or child has much difficulty in coughing up 
the thick secretion which is formed. Simple salines are preferred by some. 
Dr. Lewis Smith recommends tr. veratri viridis in half-minim or minim doses 
every second hour. As long as the cough remains hard, and the mucous secre- 
tion scanty or difficult to expel, the antimony or ipecac, should be persevered 
with, and is far more likely to be of service than the stimulating mixtures so 
often prescribed. It is when the catarrh continues, the cough becoming 
loose, the secretion liquid, and the fever is mostly gone, that carbonate of 
ammonia, squills, and terebene are most likely to be useful. At this stage 
the fomentations and poultices should be given up in favour of a warm 
cotton-wool jacket, and stimulating applications maybe applied to the chest 
Avails. Ammonia may be usefully combined with digitalis and squills, as in 
F. 60. 

Stimulating applications to be rubbed into the chest-wall are useful in 
producing slight redness without being too severe. (F. 61, F. 62, F. 63.) 
The lin. potass, iodidi c sapone B. P. may be used in a similar way. 
Iodide of potassium is often useful in the subacute or chronic stage, and 
nitric acid and nux vomica are of much service during convalescence. 

In bronchitis pure and simple the temperature is never so excessive as to 
require any antipyretic treatment, but in some cases of acute broncho-pneu- 
monia, especially where it approaches the croupous type, or when it accom- 
panies whooping cough or measles, the temperature is apt to take high flights. 
Sponging with tepid water, 'packs,' or when there is drowsiness or con- 
vulsions the warm bath gradually cooled down by adding cold water so as 
to reduce it to 6o°, may be used. Phenacetin or antipyrin may be used for 
the same purpose with care, beginning with a small dose, 2 grains of the 
former for a child of 2 or 3 years of age. Both of these antipyretics have 
been used in small doses frequently repeated, in acute bronchitis and in 
broncho-pneumonia. An excessively high temperature, io4°-io5°, is some- 
times present in an early stage of pneumonia, accompanied by convulsions 
or coma ; in such cases no time should be lost in resorting to baths or packs, 
while giving stimulants if necessary by the rectum. 

Death usually threatens in bronchitis or broncho-pneumonia from 
mechanical interference with the air entering the lungs, asphyxia being pro- 



Broncho-pneumonia 365 

•duced with great depression of the heart's action. This occurs, especially in 
young infants, by a blockage of the medium-sized and small tubes by thick 
mucus which is difficult to expel, or is due to capillary obstruction, collapse 
of lung, acute emphysema, or a large tract of lung becoming involved in the 
pneumonic process. In young infants with obstructed bronchial tubes all 
tight binding up of the chest walls by poultices or bondages must be 
avoided ; the position must be varied from time to time so as to give each 
lung full play in turn, and an occasional emetic of alum or squills will help 
to get rid of the excessive and tenacious secretion. The nurse's finger may 
be usefully employed in removing the secretion from the back of the 
throat after a fit of coughing. In suddenly produced dyspnoea either from 
collapse of lung or acute pneumonia, when the circulation through the lungs 
is obstructed and the right heart over-distended, local bleeding by means of 
a leech or two is often of the greatest service, and may be the means of 
saving life. One, two, or three leeches may be applied at the tip of the 
sternum, and after they fall off the bleeding may if necessary be encouraged 
by warm applications. Mustard baths, or mustard fomentations, or 
turpentine stupes applied to the chest are likely to be useful in those cases 
where there is extensive pneumonia with much dyspnoea and cardiac 
depression — turpentine must be used cautiously. Ammonia, strychnine, and 
digitalis must also be freely given under similar circumstances. Oxygen 
inhalation may be resorted to, but the oxygen must be given freely to be of 
much use. 

The question of the administration of emetics, alcohol and opium is of 
importance. Emetics are mostly of value in the early stages of laryngitis or 
bronchitis when the cough is hard and the breathing difficult on account of 
the swollen condition of the mucous membrane ; a freer secretion follows the 
administration, and, moreover, the unloading of the stomach of the accumu- 
lated mucus and undigested food seems to have a good effect ; ipecacuanha 
or sulphate of zinc answers best at this stage. Emetics are sometimes 
useful in a later stage of bronchitis and collapse when the bronchial tubes 
are choked with mucus, provided there is no pneumonia or cyanosis ; 10 to 
30 grains of alum in a teaspoonful of syrup of squills is preferable to 
ipecac, or zinc at this time. Alum and honey may be given to infants on a 
small brush. Alcohol is unnecessary in the early stages, and it should 
always be used with caution in the later stages, for, like opium, it soothes 
the cough, and in large quantities its effect is narcotic ; it is therefore 
contra-indicated except in small doses if there is any tendency to cyanosis. 
Opium in the form of Dover's powder is often of great value if the child is 
restless and its cough irritable, but it is perhaps needless to say it should 
on no account be given if there is much dyspnoea due to the accumulation of 
mucus in the bronchial tubes or if much lung is involved. 

During an acute attack of bronchitis or pneumonia the digestive organs 
are very apt to suffer ; there may be vomiting, flatulence, and diarrhoea. 
This impaired digestion must always be borne in mind when the question 
of dieting is being discussed, and care must be taken not to overload 
the stomach and bowels with too large a quantity of milk, beef tea, &c, 
An occasional laxative dose of calomel or rhubarb and soda may be 
useful. 



\66 



Diseases of the Respiratory Apparatus 



It is well to bear in mind the possibility that an infant may recover from 
an acute attack of bronchitis, to finally succumb to a gastro-intestinal atrophy 
dating from the acute bronchial attack. 



Croupous Pneumonia 

Croupous pneumonia in its typical form is a common disease in children 
over three years of age, and does not differ either in its course or morbid 
anatomy from the attacks in young adults, though the mortality is much 
less. Reference has already been made to the acute lobar pneumonias of 
infancy and childhood, which are frequently classed amongst the fibrinous or 
genuine croupous pneumonias on account of the extent of lung involved and 
also of their termination by crisis. That many of them are fibrinous to some 
extent is certain, as effused fibrin may be seen in sections prepared for the 
microscope, but in our experience such lungs when seen on the post-mortem 
table are more spongy and lack the complete solidity of the red hepatisation 
of true croupous pneumonia, and the outlines of the lobules are readily seen 
in consequence of their differing from one another as to the extent to which 
they are affected. Moreover, while they may contain fibrin, the cellular 
element largely predominates. Fortunately it is of little practical moment 
under which division these pneumonias are classed : hybrid cases are certain 
to come under observation both in infancy and childhood, and we have 
frequently to be content with describing attacks as being of the ' croupous 
type,' or of the 'catarrhal' or 'broncho-pneumonic' type, according as their 
symptoms resemble typical attacks of either the one or the other. It is the 
difficulty of classifying hybrid cases that makes the statistics of one hospital 
or one year liable to error when compared with that of other hospitals or 
years. 

The statistics (given below) of our own hospital of the cases entered as 
croupous pneumonia during the years 1 878-1 893 illustrate the comparative 
frequency of the disease at different ages. In this series of cases the total 
mortality amounted to 5*2 per cent, the highest being among children under 
two years of age. 1 

Table showing the Ages and Mortality of 708 Cases of 
Croupous Pneumonia 



Under 2 years 


2 to 5 years 


5 to 10 years 


10 to 14 years 


Total 


Deaths 


Total Deaths 


Total Deaths 


Total 


Deaths 


Total 


Death 


29 8 


213 21 


338 


8 


128 


I 


708 


38 



The etiology of croupous pneumonia is not perhaps quite as simple as it 
seems at first sight. A schoolboy is exposed to a cold east wind after 
getting hot, or is chilled by a fall into water, and a few days later develops 
an acute pneumonia : in such cases there can be little doubt that pneumonia 

1 These figures closely correspond with those given by Yon Dusch ; in 331 of his cases 
of croupous pneumonia in children under 10 years of age the mortality was 4-8 per cent. 



Croupous Pneumonia 367 

in some way or other is the result of a chill. In connection, however, with 
this, our own hospital statistics do not show much difference in the number 
of cases admitted during the different months of the year, though there is a 
slight preponderance in favour of March. 1 Attacks certainly occur at all 
times of year, in the warmer as well as in the colder months. On the other 
hand, it is quite certain that croupous pneumonia is at times epidemic and 
also infectious, affecting several members of the same household or the same 
street, and in a few instances there have been widespread epidemics, as, for 
instance, during the influenza epidemic of 1891. Epidemics of pneumonia 
associated with tonsillitis have occurred in schools and other large institutions 
where the sanitary arrangements have been found faulty. It may be taken 
for certain that while there is a form of pneumonia of the croupous type 
which follows a chill, it may be produced by other causes, such as infection by 
the inhalation of the Frankel-Weichselbaum diplococcus or the influenza 
bacillus, or it may be part of some general septic poisoning. In some 
instances acute pneumonia has followed injury ; a blow on the chest or a 
fall on the head has been followed a few days later by a pneumonic attack. 

It seems to us that it is more than probable that these micro-organisms 
are incapable of setting up pneumonia in healthy lung in a normal condition ; 
but if the individual has caught cold or is in a low state of health a suitable 
soil is produced, and if an infection takes place a pneumonia is the result. 

The pneumonic diplococcus appears to be almost constantly present in 
the sputa of cases of croupous pneumonia in the early stage, but it is also 
found in the pus from an acute otitis and also in the effusion in cerebro- 
spinal meningitis. It has been found in the sputa of healthy children. It 
can hardly be said to be pathogenic of pneumonia, but it is apparently 
capable of setting up pneumonia under certain conditions. 

In different epidemics, or in different years or localities, attacks of 
pneumonia appear to vary in their character, sometimes being of the 
sthenic, sometimes of asthenic type : this has been specially described by 
Foxwell.' 2 

Symptoms and Course. — The onset is sudden, with symptoms not unlike 
those of scarlet fever ; there are high fever, dyspnoea, rapid pulse, headache, 
pain in the side or abdomen, short cough, and perhaps vomiting and 
diarrhoea. In children under three years convulsions are not uncommon at 
the onset, but these are rare in older children : the convulsions may prove 
fatal before the attack of pneumonia has fully declared itself. Delirium may 
be an early symptom, especially if the fever is high. By the time a medical 
examination is made the child is usually too ill to be about, and is either in 
bed or being nursed in its mother's arms ; the cheeks are flushed, the alae 
nasi are working, the respirations are perhaps doubled, being possibly 40 
per minute or more, the pulse 120 to 140, there is a temperature of 104 or 
thereabouts, the tongue is dry and brown, and there may be herpetic vesicles 
on the lips and nose. An examination of the urine shows it to be dark in 
colour, concentrated, containing albumen and an excess of urea, and deficient 
in chlorides. The cough is dry and hacking, and pain is often complained of 

1 In 628 cases of croupous pneumonia during the years 1857-1885 Durasz found a 
slight excess in April and May. 
- Practitioner, July 1886. 



368 Diseases of the Respiratory Apparatus 

during the act ; in young children there is no expectoration, in older ones 
there may be the usual rusty sputa. The fever and dyspncea continue, the 
child remaining very ill till the end of the week, when, usually between the 
sixth and the ninth day, the fever suddenly abates, and a marked improvement 
takes place in all the symptoms, so that it is evident to all that the crisis has 
come. The crisis is sometimes marked by collapse, the child becoming cold 
and clammy, with a subnormal temperature. 

Physical Signs. — An examination of the chest on the first or second day 
of the attack will usually lead to the discovery of more or less consolidated 
lung. Careful percussion, striking now lightly, now more forcibly, will elicit 
a certain high-pitched note of impaired resonance over some part of the 
chest wall, as in the infra-clavicular, axillary, or scapular region, or over the 
root or base of the lungs ; on listening over the affected area some departure 
from the normal breath sounds will probably be heard. They may be 
simply weak or distant breathing, as if the air is not entering freely into 
some part of the lung ; there may be distant or intense bronchial breathing, 
of various abnormal sounds, as a pleuritic rub, rhonchus, or, more often, 
subcrepitant or loose ringing rales, the fine crepitation so common in adults 
being generally absent. There are usually increased vocal resonance and 
fremitus, though it is not always possible to elicit these signs unless the child 
cries. If there is much lung affected, loud or harsh breath sounds are heard 
over the non-affected lung, and care must be taken not to mistake these signs 
of an overworked, for those of an affected lung. 

The position of the consolidation varies considerably and does not 
necessarily correspond to a lobe, but may occupy the whole extent of lung 
anteriorly or posteriorly ; or the most marked signs man be first detected over 
the root of the lung behind or in the axilla. The left base and right apex are 
favourite spots to be attacked, but any part of the lung may be involved, 
though it must be borne in mind that the apices are more apt to be affected 
in children than in adults, and it is just at this spot that early signs are apt to 
be overlooked. In the course of a day or two, sometimes not for several, the 
physical signs become more marked, the dulness cannot be mistaken, the 
bronchial breathing becomes whiffy and intense ; in a few days more, usually 
after the crisis has arrived, coarse, loose, crepitant rales are heard which 
mark the resolution of the pneumonic lung. The dulness and .bronchial 
breath sounds and rales disappear, but some want of resonance is apt to 
remain for many weeks, as the lung remains in an cedematous state. While 
such is the usual cause of events in an ordinary case, there are marked 
differences with regard to the time when the physical signs make their appear- 
ance, there being frequently a delay of several days ; they may even appear 
as late as the fifth day. It is important to remember this, for a mistake in 
diagnosis is easy, as a most careful examination of the whole chest may reveal 
nothing suggestive of pneumonia. In such cases there is a strong presump- 
tion that the pneumonia is centrally situated, perhaps at the root of the 
lung, and takes some time to approach the surface ; or possibly there may 
be an acute inflammatory congestion of a portion of lung and a delay in the 
transudation of fibrin into the air-sacs. Often a sub-tympanitic or actually a 
tympanitic note to percussion and weak bronchial breathing, or simply 
distant respiratory sounds, may be all there is to be heard for a day or two. 



Croupous Pneumonia 



369 



It is not easy to say why a tympanitic or 'boxy' note is elicited over lung 
in a state of acute inflammatory congestion, or in the first stage of an acute 
lobar pneumonia, but that it does occur we have often had the opportunity 
of observing. In a few cases the crisis may come and the child recover 
without the classical signs of pneumonia ever being present. 

Temperature. — The temperature usually goes up suddenly at the onset 
to 1 04 or thereabouts, and during the course of the attack continues high, 
with slight morning remissions, till the crisis, when the fall is sudden (see 
fig- 7o), perhaps 4 or 5 , to a subnormal temperature ; the latter may last for a 
few days, and then the normal line be regained. The day on which the crisis 
takes place varies greatly ; the attack may end about the fourth or fifth day 




Fig. 70.— Temperature Chart of a case of Croupous Pneumonia of left apex in a girl of five years. 
Crisis sixth day. Recovery. 

or earlier, but usually the crisis is delayed till the seventh or eighth, and in 
the creeping form till the end of the second week or later ; a post-crisial 
rise often occurs (see fig. 71), the temperature rising a few degrees the fol- 
lowing evening, becoming normal the next morning ; or a relapse in which 
the temperature remains elevated may take place in consequence of another 
portion of lung being affected. Post-crisial hectic, prolonged for some days 
or weeks, suggests the presence of an empyema or other complication. In 
the minority of cases the temperature falls by lysis. 

Varieties.— The. course of the attack varies ; these varieties have been 
emphasised by various writers, especially by A. Baginsky ; they may be 
enumerated as follows: (1) Abortive Pneumonia. This variety, as the 

B B 



370 Diseases of the Respiratory Apparatus 

name applies, aborts, or the course comes to a sudden termination by crisis, 
after lasting two, three, or four days, mostly without the classical signs of 
pneumonia being developed ; yet a careful examination of the lungs will 
discover some spot where the breath sounds are weak and the percussion 
note slightly raised or tympanitic. Herpes is common on the lips and 
nose. (2) Creeping- or wandering Pneumonia has been compared by 
Henoch to an attack of erysipelas spreading over the surface of the lung. 
The apex is perhaps the first part affected ; gradually the inflammatory 
process spreads to the base, and possibly finally attacks the opposite side. 
Such cases are apt to have a chronic course, the crisis being delayed till the 
tenth or fourteenth day, or the temperature may fall by lysis, or a hectic may 
succeed in consequence of an empyema being present. (3) Relapsing 
Pneumonia much resembles the creeping form. Several relapses occur 
after the crisis has come, some patch of pneumonia occurring in another 
part of the lung. We have known cases in which six or seven relapses have 
occurred. In such cases we may suspect pus. (4) Cerebral pneumonia. — 
In this form cerebral symptoms are prominent, while, in the early stages at 
least, the symptoms of pneumonia are latent ; there may be convulsions, 
delirium, headache, and drowsiness. In such cases the fever usually runs 
high, and the cerebral symptoms may be due to the high fever and poisoned 
blood. Not unfrequently the lesion in these cases is at the apex. Cough is 
often absent. (5) Gastric Pneumonia. — In these cases gastric symptoms 
are most marked ; the attack may begin with vomiting, diarrhoea, coated 
tongue, fever, and abdominal pain, and it is only after a day or two, when 
the classical signs appear, that a diagnosis of pneumonia is made. The 
attack may simulate gastro-intestinal catarrh or peritonitis, the abdo- 
minal pain being due to diaphragmatic or costal pleurisy. (6) Pleuro- 
pneumonia. — In these cases the signs of pleurisy predominate ; there is 
sharp stabbing pain, tenderness on percussion, and the child screams when 
it coughs or turns over in bed. Signs of consolidation are succeeded by 
those of pleuritic effusion, or an empyema possibly results. 

Comftlicatio?is and Sequela?. — Pleurisy frequently accompanies croupous 
pneumonia ; percussion over the dull area and deep pressure give pain, and 
friction sounds are frequently heard ; the pleurisy is apt to become suppura- 
tive in weakly children, especially if the pneumonia occurs in the course of 
scarlet fever, measles, or whooping cough (see infra). Pericarditis some- 
times occurs. Hyperpyrexia, a temperature of 105 or 106 occasionally 
taking place, accompanied by cerebral symptoms, convulsions in young 
children, or stupor and delirium in older ones. Meningitis is rare, though it 
occurs occasionally simultaneously with the pneumonia or follows as a sequela, 
being most common in young children. Nephritis also occurs in associa- 
tion with pneumonia ; usually the latter is secondary to the former. Jaundice 
sometimes accompanies pneumonia, especially of the right base (see p. y]^). 
Gangrene of the lung occasionally supervenes and brings about a fatal 
result ; this seems mostly to occur either in pneumonia secondary to neph- 
ritis, or when pneumonia occurs in a subject who has emphysematous lungs. 
The possibility of the lung being adherent to the chest and undergoing an 
indurating or fibroid process must be kept in mind. A chronic condition of 
caseation may remain, but this is much commoner after catarrhal than after 



Croupous Pneumonia 



371 



croupous pneumonia. Diphtheria of the fauces may complicate it ; once 
or twice we have discovered, to our surprise, late in the attack or on the 
post-mortem table, false membrane on the fauces. 

Prognosis. — The prognosis is favourable in cases of croupous pneumonia 
when it is primary and attacks healthy children over three years of age ; 
among such the mortality is small. Double pneumonia is necessarily more 
fatal than single, but here the amount of lung involved at one time is not 
necessarily great, as usually while it is advancing on one side it is receding 
on the other ; the danger depends on the amount of lung involved, and the 
respirations give a more or less useful indication of this. In a child who 
already suffers from chronic bronchitis and emphysema or cardiac disease, 



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Fig. 



-Temperature Chart of a case of Croupous Pneumonia of left lung in a girl of five years 
treated by cold baths. Crisis fourth day ; post-crisial rise. Recovery. 



the prognosis is much worse. Secondary pneumonia, when it follows or 
complicates scarlet fever, measles, whooping cough, nephritis, or follows 
operations oris connected with septicaemia, is necessarily serious and often 
fatal disease. When much pleurisy accompanies the pneumonia, especially 
in young children, the prognosis is less favourable than in cases of simple 
croupous pneumonia. 

Diagnosis. — In those cases of croupous pneumonia which begin with 
vomiting and high fever, and where the physical signs are delayed, there is 
a. certain superficial resemblance to scarlet fever. That such cases are liable 
to be mistaken for scarlet fever is shown by the fact that not uncommonly 
cases of acute pneumonia are sent into fever hospitals certified as suffering 



37 2 Diseases of the Respiratory Apparatus 

from scarlet fever. A careful examination of the patient, and, if necessary, a 
delay of twenty-four hours before coming to a decision, will, in the large 
majority of cases, prevent such an error. In the first twenty-four hours in a 
sharp attack of scarlet fever there may be high temperature, vomiting, diar- 
rhoea, rapid pulse (often 150), tonsillitis more or less developed, no pain in 
the chest, or cough. The rash usually appears at the end of twenty-four hours. 
In acute pneumonia there may be high fever, headache, pain in the chest or 
abdomen, dyspnoea, pulse perhaps of 120, perhaps some physical signs in 
the chest, not often vomiting, diarrhoea, or tonsillitis. There is no rash. 
Acute pneumonia with marked cerebral symptoms, such as delirium, stupor, 
or headache, sordes on the teeth, and high fever may be taken for typhus. 
A careful examination of the lungs would generally decide ; in typhus there 
> may be evidence of bronchitis ; in pneumonia there would usually be some 
want of resonance at an apex or base, with some distant or bronchial breath- 
, ing. The presence of a characteristic rash on the third or fourth day would 
decide the diagnosis ; it is well to remember that in children typhus is usually 
a mild disease. In young children an acute attack of croupous pneumonia, 
with high fever, convulsions, drowsiness, or coma, may be mistaken for acute 
meningitis, or, as a matter of fact, pneumonia and meningitis may co-exist. 
We should, however, hesitate in the presence of pneumonia and a temperature 
of 104 or 105 to diagnose meningitis, the cerebral symptoms being due to 
the high temperature and poisoned blood. In all cases where a young child 
is suddenly taken with convulsions and high fever, pneumonia should be sus- 
pected and a careful examination of the lungs made. We must remember 
that the temperature may be high, io4°or 105 , as the result of only a small 
patch of pneumonia. In such cases, especially in infants, the pneumonia may 
be overlooked and the temperature be attributed to teething. The diagnosis 
between croupous pneumonia and generalised broncho-pneumonia may not 
be easy during life • we cannot often do more than say such and such an 
attack approaches more nearly to the croupous type, when there is a sudden 
onset, a local portion of lunginvolved, a continuous temperature, and a crisis ; 
that it is more of the catarrhal type when there is much bronchitis, an inter- 
mittent temperature, and gradual, subsidence of the fever. The difficulty does 
not always end in the post-mortem room, as typical fibrinous pneumonia in 
patches or more widely distributed may be found in one lung and undoubted 
lobular pneumonia in the other, while both varieties may be present in the 
same lung. 

Pathology. — In croupous pneumonia the first stage is that of an inflam- 
matory engorgement of an extended portion of lung, the vessels are full, the 
capillaries are tortuous and distended, encroaching on the air space in the 
sacs ; in the second stage the engorged vessels relieve themselves by pouring 
out liquor sanguinis and some corpuscular elements into the air sacs, which 
become blocked with fibrine, and a condition of red hepatisation results. 
This red hepatisation, when seen at the post-mortem, differs from the lobar 
variety of catarrhal pneumonia in that it is more solid to the touch, and 
presents a uniformly coloured surface on which the outlines of the lobules 
cannot be distinguished ; in children it is less often granular than it is in 
adults. In a later stage grey hepatisation is found, the lighter colour being 
due to the presence of a greater number of corpuscular elements. In lung 



Croupous Pneumonia 373 

in a state of red hepatisation, Frankel-Weichselbaum diplococci may be 
usually detected by Gram's method. In one of our recent cases of fatal 
croupous pneumonia, in a boy of four years of age, who died on the eighth 
day (having been deeply jaundiced for three or four days), the left lung was 
in a condition of red and grey hepatisation, except at the extreme apex. 
There were some localised hepatised patches in the right base. We were 
able to obtain cultivations on glycerine agar of the Frankel-W. diplococcus, 
Staphylo-coccus pyog. aureus, and Strepto-coc. pyogenes. 

Treatment. — -An uncomplicated case of croupous pneumonia in a child does 
not require active treatment, as the course is short, and the heart and arterial 
system, unlike the condition often found in adults, are free from degenera- 
tions, and able to stand the strain imposed upon them. The child should, of 
course, be confined to his bed in a well warmed and ventilated room ; he 
should be allowed only fluid nourishment, such as milk, barley water, and 
soda water. A piece of spongio-piline or flannel doubled several times 
may be wrung out of hot water, and applied to the chest. Poultices may be 
used, and retain the heat better than anything else ; but they are very 
liable to slip out of place, and are unsuited for infants on account of their 
weight. In the early stages aconite is of service, one or two drops of the 
tincture being given every two or four hours, being watched carefully lest it 
produce too much depression. In many cases no other treatment is required, 
the aconite being stopped when the crisis comes. If the temperature is not 
excessive, not much exceeding 103 , no special methods of reducing it need 
be used, as the course of the fever is short, and often after the first day or 
two it takes a lower range ; the initial fever in the case of infants and young 
children is in some cases high, and is, apparently, the cause of the cerebral 
symptoms, such as convulsions and coma, from which they suffer, and 
which sometimes prove fatal. When this is the case, no time should 
be lost in reducing temperature by cold sponging, packs, baths, an ice 
bag to the chest over the seat of the pneumonia, or by the administration 
of antipyretics. If the temperature is high — 104 or 105 — there is no 
need to fear any harm accruing from cold water, the simplest method of 
applying it being by sponging the patient, or — what is more effectual — by a 
pack at 6o° or 70 ; this latter can be applied by wringing a towel out of 
cold water, folding and applying it round the chest, or enveloping the whole 
body in a wetted sheet. The process may be repeated at intervals of an hour 
more or less. If these means prove inefficient, or if, as in the case of con- 
vulsions, there is no time to lose, the cold or graduated bath should be 
resorted to, the child being placed in a warm or lukewarm bath, and the 
temperature of the water gradually lowered to 6o° F. by addition of cold 
water or ice ; if the patient becomes blue and cold he should be removed at 
once. 

The best antipyretics are quinine and phenacetin, either being given in 
two or three grain doses to a child of. three years every four hours ; 
phenacetin is apt to produce considerable depression, which, however, 
quickly passes away ; large doses of quinine are apt to produce dyspepsia. 
The effects of aconite on the pulse should be carefully watched ; any signs 
of intermission or irregularity should be the signal for omitting it, for a while 
at least, and giving some simple saline, as liq. ammon. acet. or citratis ; 



374 Diseases of the Respiratory Apparatus 

alcohol and stimulant expectorants are best avoided in the early stages ; two 
or three drop doses of tr. digitalis, given every four hours, are often useful 
if the pulse is poor ; citrate of caffeine or sulphuric ether may also be 
given. 

In cases where the crisis is delayed on account of the inflammatory process 
extending, as in the creeping form, and when the child seems low and weak, 
there is always a temptation to give ammonia and stimulants, and these may 
in some cases be needed, especially in hospital patients who are seen for 
the first time after some days' illness ; but our impression is that patients do 
better in the inflammatory stages, when the process is still extending, on 
small doses of aconite, antimony, or salines, than they do on a too stimu- 
lating treatment. An occasional dose of alcohol may do good when a con- 
tinuous dosing is harmful ; alcohol in large doses acts as a narcotic, and is 
apt to add to the drowsiness and tendency to delirium. Opium in the form 
of 'nepenthe' or Dover's powder is of great value in calming the delirium 
and sleeplessness, as well as soothing the irritable cough and relieving pain 
when this is a marked feature, as it is in the pleuritic complications. One 
to three drops of nepenthe or half to two grains of Dover's powder may be 
given at night to procure rest and sleep. In double pneumonia, where there 
is much depression with a failing pulse, ether and digitalis must be resorted 
to. Ether may be injected in three or five drop doses subcutaneously, or sp.* 
aetheris and tr. digitalis may be given every few hours, or inject strychnine 
subcutaneously in doses of T fo --£$ of a grain, every hour. Champagne is a 
g'ood restorative under these circumstances, but it may cause vomiting if 
given too freely, and it will be well to dilute it with soda water in the case of 
young children. 

■Gangrene of the Lung 

Croupous pneumonia, when it attacks children already the subjects of 
chronic bronchitis and emphysema, is apt to terminate in gangrene of the 
lung ; this we have seen on several occasions. It is apt to follow pneumonia 
secondary to scarlatinal nephritis and also whooping cough. The principal 
diagnostic symptom is the exceedingly foul breath ; the temperature is 
usually high, sometimes hectic, suggesting pus, and the pulse is rapid. The 
lung is found at the post-mortem in a state of grey hepatisation, "breaking 
down into ragged cavities and smelling offensively. 

Gangrene of Lung ; Pyopneumothorax. — Joseph P., aged 9 years. Mother states 
he has been subject to bronchitis in the winter. On September 10 he came from school 
complaining of a pain in his side and bad cough. He has been spitting some blood. 
On admission, September 27, 1894, he is a thin, delicate-looking boy, with clubbed 
fingers. On examination of the chest : the right side has a boxy note, except at the base, 
behind which is dull ; the breath sounds are very faint ; some friction sounds in the axilla ; 
the left side is normal, except that the breath sounds are exaggerated. There is not much 
dyspncea, but he is subject to paroxysms of coughing, when he brings up considerable 
quantities of very foetid pus. October 2. — Paroxysms of coughing and foetid expectora- 
tions ; some dulness at left base behind. Coarse crepitation anteriorly on right side. 
Explored right side subcutaneously in several different places, but failed to find pus. 
October 3. — Much collapse. Death October 6. 

Post-mortem. — Right lung adherent in front, in axillary region pyopneumothorax ; 
pus very foul ; small cavity in middle of lobe, communicating with bronchus and also 



Pleurisy and Empyema 375 

pleural cavity ; patches of consolidation throughout the lung becoming gangrenous ; no 
definite tubercle. Left lung adherent behind ; recent pleurisy. Heart and other organs 
show nothing abnormal. 

Abscess of the lung 

Purulent collections in the lungs are mostly the result of septic embolism 
from some distant suppurating centre, as in an otitis or some other bone 
lesion, and are associated with pyaemia. They are usually small and situated 
on the surface. Small abscesses may be secondary to an empyema, the latter 
finding its way via a small abscess into a bronchial tube. Minute abscesses 
are sometimes a sequence of a broncho-pneumonia secondary to scarlet 
fever, measles, or whooping cough, suppuration taking place in the lobules 
immediately surrounding the terminal bronchioles ; here small centres con- 
taining pus may be found (see p. 360). 

In both gangrene and abscess of the lung, if the lesions are fairly 
localised, or the disease progressing, an attempt should be made to 
arrest the mischief by incising and draining the abscess or gangrenous 
cavity. For this purpose it is necessary to localise the abscess, first by the 
physical signs as far as may be, and, secondly, by exploration with an 
aspirator needle, though, if the evidence is otherwise strong, failure to draw- 
off pus by the aspirator should not prevent a further exploration ; the incision 
should be made over the abscess, and, if necessary, one or more segments 
of rib removed ; the lung should then be incised and drained, and treated on 
ordinary surgical principles. We have incised and drained a hydatid of the 
lung and a pulmonary abscess, with considerable relief to the children in each 
instance. 

Pleurisy and Empyema 

That pleurisy must be a common disease in children is shown by the 
frequency with which the lungs are found adherent to the chest walls when 
making autopsies on children who have died from various diseases Here, 
as in the case of adults, the evidence of a past pleurisy is conclusive. Yet it 
cannot be said that pleurisy is diagnosed and treated with any great 
frequency during life, the reason no doubt being that young children are not 
able to localise attacks of pain, that when fretful it is not easy to thoroughly 
examine their chests by auscultation, and, moreover, the symptoms may be 
masked by other diseases in which the pleural lesion plays but a secondary 
part. 

Pleurisy, primary and acute, occurs at all ages during infancy and child- 
hood, the first year of life being by no means exempt. It is apt to follow 
exposure to cold, or, not infrequently, an accident, such as a fall or blow on 
the chest. It is, however, far more commonly associated with a croupous, 
catarrhal, or septic pneumonia. It occurs very frequently in connection with 
tuberculosis of the lung. 

Symptoms. — Pleurisy may begin suddenly and run an acute course, though 
more often it is subacute. The attack begins with a short cough, fever, 
shallow respiratory movements, the affected side moving less than its fellow, 
accompanied by sharp pain, which the child, if old enough to do so, refers to 
the side or very often the epigastrium. In infants the attack my be ushered 



376 Diseases of the Respiratory Apparatus 

in by convulsions and its course may be marked by screaming fits, especially 
if the child is disturbed. If the pleurisy is extensive and acute, an examina- 
tion of the chest shows the respirations to be shallow, and the movements of 
the affected side extremely limited, while percussion or pressure in the 
intercostal spaces with the finger gives rise to expressions of acute pain. 
On auscultation, while the breath sounds are loud and clear on the normal 
side, they are weak on the affected, and perhaps accompanied by a friction 
sound. The pulse is quickened and there is fever, perhaps ioo° to 102 , 
unless pneumonia is present, when it is probably higher. The further course 
of the attack varies according to whether effusion of serum occurs or not. 
In the latter case, in the course of a few days the fever subsides, the friction 
sounds disappear, though perhaps some ' stitch ' (stabbing pain in the side) 
remains for a while. In many cases apparently a local pleurisy takes place 
during the course of a bronchitis or bronchial catarrh in which little else 
than a sharp pain in the side or abdomen is present. 

In pleurisy occurring between the diaphragm and lung the symptoms are 
generally obscure, there is pain and tenderness in the epigastric or hepatic 
region, with thoracic breathing, the abdominal muscles and diaphragm being 
kept as quiet as possible. Should effusion take place in any quantity, 
signs of its presence quickly appear. The child will probably lie on the 
affected side, so as to give full play to the lung on the sound side ; the infant, 
as Henoch points out, with fluid in the right pleural cavity takes only the left 
breast of its mother for a similar reason. On inspection it will be noted that 
the side containing the effused fluid moves less freely than the other, and if 
the fluid is in the left chest, the cardiac impulse is displaced towards the 
right side. In large pleural effusions on the right side the impulse may 
be moved towards the left. This displacement of the cardiac impulse is 
of special value in the diagnosis of fluid in the chest in children, on account 
of the uncertainty and small value of some of the other physical signs ; 
as, for instance, the vocal resonance and fremitus, which yield valuable in- 
formation in adults. The position of the heart's impulse is best ascertained 
by placing the surface of the hand on the chest wall, and, if necessary, by 
determining by auscultation the position of the heart by the comparative 
loudness of its sounds. It is necessary, however, to remember that the heart 
may be displaced without any fluid being present at the time of examination, 
as it may have been pushed on one side by a former effusion and have become 
fixed in an abnormal position by fibrous adhesions ; in this case the lung also 
will probably be adherent, and a dull note may be elicited over it which 
suggests the presence of fluid. The heart may also be pulled on one side or 
upwards by a fibroid condition of lung or chronic pleurisy. 

On percussion of the chest, a dull or much impaired resonance will be 
detected over the area occupied by fluid, while in most cases the sub- 
clavicular region and frequently also the supra-spinous fossa and possibly a 
strip between the base of the scapula and the spine will be resonant, often 
hyper-resonant. If the effusion is great the whole side will be completely 
dull and give a sense of resistance on percussion. On auscultation the 
breath sounds are weak and distant, but usually of a distinctly bronchial or 
tubular character. In the earlier stages of effusion the expiratory murmur 
is especially accentuated and bronchial, the air from the compressed lung 



Pleurisy 377 

"being, as it were, expelled with difficulty. The breath sounds on the healthy 
side are exaggerated. The vocal resonance and fremitus may be absent or 
weak, but it may be impossible to elicit any information in this way, as the 
voices of children, especially girls, are weak, and moreover they may not be 
old enough to understand what they are wanted to do. During crying, in- 
formation of value may sometimes be obtained by placing the hand on the 
•chest. Comparative measurements of the two sides show the affected 
side in recent cases to be larger than the other ; but too much value must 
not be attached to measurements, as in chronic cases some amount of re- 
traction may have taken place. Of more value is the cyrtometer tracing ; 
this, as pointed out by Dr. S. Gee, shows a change of shape from the 
elliptical to the more circular form without the circumference necessarily 
being increased. 

Should a large amount of fluid be poured out in a short space of time, it 
will necessarily give rise to dyspnoea : the child will turn over on to the 
affected side or lie upon its back ; the alae nasi work, and the number of re- 
spirations is increased perhaps to forty or fifty. If the amount of fluid is 
smaller in quantity, the child may be tolerably comfortable while lying at 
rest, but there is dyspnoea on the slightest exertion. The amount of feverish- 
ness varies ; during the inflammatory stage before or during the period the 
serum is being poured out the temperature is usually raised two or three 
degrees ; in the course of a few days a gradual fall takes place, and there may 
be no fever or only a slight elevation at night. 

Under favourable circumstances in a healthy child, the serum effused 
begins to be reabsorbed : this it usually does in the course of a few days, 
the heart if displaced returning by degrees to its normal position, the level of 
the fluid becoming lower and lower, till the side regains its normal resonance ; 
or, what is much more likely, a somewhat impaired resonance, which it retains 
for many weeks. The reason of this is doubtless that the re-expanded lung 
remains for some time in a sodden and congested state, and not improbably 
its pleural surface contracts adhesions with the chest wall. During the 
stage of i-eabsorption friction and moist rales are frequently heard in the 
lung, and the breath sounds are weak. In some cases, however, this desirable 
reabsorption does not at once take place. The child's health is impaired, 
he is anaemic and depressed, perhaps thick layers of lymph are covering the 
pleural surface of the lung and chest wall, and conditions are not favourable 
for the reabsorption of the fluid after the inflammation has subsided ; or 
possibly the absorption may go on extremely slowly, pari passu with the 
organising of the lymph which has been poured out. Under these circum- 
stances much damage may be done, the heart may be fixed in a malposition, 
the lung may become tied down by a thick layer of fibroid tissue which, 
contracting, holds the lung in its grip, while the chest falls in and the spine 
becomes curved. 

But besides a quick reabsorption of the serum, and a chronic pleurisy 
with its slow course, another result may follow, and that is — at least this 
is what is usually believed— the serum may become pus ; this, however, is not 
a common result if the fluid effused is at first serum, and it rarely happens 
that it remains so for some weeks and then finally becomes converted into 
pus. An empyema, as a rule, is an empyema from the first, at least the fluid 



37 8 Diseases of the Respiratory Apparatus 

effused is turbid-looking at first ; in other words, it is thin pus, and later it 
becomes thick pus. It is no doubt most common to find that where there is 
reason to believe fluid has existed in the chest for some weeks or months, 
the fluid is pus and not serum, but then in all probability the fluid has been 
pus from the first and has failed to be absorbed, whereas had it been serum 
it would have been. Serum may undoubtedly remain in the chest unaltered 
for many weeks, perhaps months ; but this is uncommon except in cases of 
tubercle, or new growths in the lung, or in cardiac disease. An empyema is, 
in the vast majority of instances at any rate, the result rather of a pleuro- 
pneumonia than a simple pleurisy. The more intense the inflarrimation 
the more likely it is that pus, not simple serum, is poured out, or that 
the serum poured out quickly becomes pus. This is especially likely to 
happen if a pleuro-pneumonia follows scarlet fever, measles, or whooping 
cough, or indeed any pneumonia of the croupous type. The symptoms given 
by an empyema are by no means distinctive as between pus and serum, and 
often no definite diagnosis can be arrived at until an exploratory puncture 
has been made. In favour of pus in acute cases would be the occurrence of 
pleurisy as a sequel of a zymotic disease, especially in a weakly child ; in 
chronic cases the presence of hectic, diarrhoea, a sallow earthy complexion, 
the ' pointing ' of a collection of fluid in connection with the chest. A collec- 
tion of purulent fluid may be present in the chest and give very few signs of 
its presence, except the physical signs. It must be remembered that in any 
chronic case of fluid in the chest in a child, that fluid is probably pus, but not 
universally so. The early history of an empyema is generally that of an 
acute pneumonia which does not clear up, and the presence of pus in the 
chest is likely to be thought to be consolidation of the lung, especially as 
there maybe well-marked bronchial breathing. As an illustration of this 
the following case may be cited. 

A girl of nine years was convalescent from scarlet fever. On the thirty-eighth day the 
temperature rose to 105", there was intense pain referred to the left side of the chest and 
epigastrium, especially felt when she turned in bed, there was also some want of resonance 
at the left apex. On the third day of the attack there was diminished resonance over the 
whole left side, with bronchial breathing ; no displacement of the heart. On the sixth day 
there was slight displacement of the heart to the right, the dulness over the left chest was 
much more marked, the breath sounds were faint and bronchial. On the eleventh day 
the signs of fluid had increased, the heart's impulse being felt at the left border of the 
sternum ; an exploratory puncture showed the presence of pus. On the seventeenth day 
the chest was incised antiseptically, pus and much lymph escaped, a tube was inserted, 
and complete recovery ensued (see fig. 72). 

It must always be borne in mind if a croupous pneumonia does not clear 
up and the dulness disappear, or if the temperature remits instead of 
falling when the time for a crisis comes, pus may be present in the chest. 
In such cases the signs of consolidation of lung are gradually replaced by 
those of fluid, the latter accumulating as the pneumonic consolidation dis- 
appears. 

Pus may be present in the chest, yet not free in the pleural cavity, but 
confined by adhesion between the lung and chest wall or diaphragm. More 
than one localised empyema may be present on the same or opposite sides. 
Such localised collections may be present in any part, as at the apex in front, 



Empyema 



379 



the base behind, or in front between the pericardium and anterior edge of 
the left lung, or between the lung and the diaphragm. We have known a 
localised empyema situated at the posterior side of the apex of one lung ; 
there was fairly good resonance in front and behind, except over a small area 
at the back of the apex of the lung. These small empyemas are often asso- 
ciated with broncho-pneumonias and chronic tuberculosis of the lung. It is 
perfectly obvious that if these collections of fluid are not large and are sur- 
rounded by and backed up by crepitant lung, diagnosis will be by no means 
easy, and it is not surprising that such should be found on the post-mortem 
table, having escaped discovery during life. In these cases the physical signs 
are not distinctive ; there Avill mostly be a patch of dulness, with more or 
less resistance, but an adherent lung with thick fibroid tissue between it and 
the chest wall will give a similar note. The breath sounds are weak, perhaps 



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Fig. 72. — Temperature Chart of a case of Pleuro-pneumonia followed by Empyema, in a girl of 
nine years. Signs of fluid were discovered on the sixth day. pus on the eleventh day ; on the 
seventeenth day the chest was incised, followed by a fall in the temperature. 

bronchial. When in doubt it is wise to explore, not using too fine a needle, 
as if the bore is too small it is apt to become blocked with a flake of lymph 
or pus. If the layer of pus is not thick the needle may pass through the pus 
into lung beyond. 

Diagnosis. — The distinction between the consolidation of pneumonia and 
pleuritic effusion in typical cases is made readily enough. The intense 
bronchial breathing, with the clear, ringing rales and impaired resonance of 
pneumonic consolidation, form a marked contrast to the weak, distant breath 
sounds, wooden dulness, and displaced heart distinctive of a large effusion 
of fluid. In many cases, however, no diagnosis is possible without an ex- 
ploratory puncture, and even then a negative result does not definitely settle 
the matter, as it is quite possible to miss the fluid. A pneumonic lung 
covered with a thick layer of lymph, or a sodden lung covered with fibroid 
tissue and adherent to the chest wall, gives a wooden dulness and resistance 



380 Diseases of the Respiratory Apparatus 

closely resembling that of fluid. On the other hand, when fluid is present 
the bronchial breathing is sometimes loud and even intense. A good rule 
to follow is, whenever there is a patch of dulness that does not clear up, 
especially where there is a hectic or elevated temperature, always to explore 
by means of a subcutaneous syringe. The diagnosis between a local or 
small collection of fluid at a base and chronic pneumonia, caseous pneumonia 
and tubercular consolidation, is often far from easy, and indeed is generally 
impossible without exploration. There may be dulness and a hectic tem- 
perature, moreover there may be a patch of impaired resonance in the axilla 
while the apex and base are resonant, or both sides may be affected. 

In one of our cases there was intense bronchial breathing and increased 
vocal resonance over the whole of the right lung, except at the base ; it 
was very dull all over. We removed 7 oz. of pus and more drained away 
afterwards. 

Morbid Anatomy. — It is not often that an opportunity occurs of examin- 
ing the chest of a child that has died of uncomplicated pleurisy or empyema, 
though it is common enough to find both in association with pneumonia or 
tuberculosis. The pleurisy differs much in degree, from a simply roughened 
surface to a layer of thick lymph ; the adhesions which result from the 
organising of the lymph also varying greatly in toughness and thickness. 
Serum in varying amount, perhaps in greater quantity than was suspected 
during life, may be found in association with pneumonia, especially in such 
diseases as nephritis, septicaemia, and scarlet fever. The lung corresponding 
to the position of the fluid is collapsed and airless. The result of a past 
pleurisy, especially when this has been chronic, is sometimes seen at the post- 
mortem in the shape of thick fibroid adhesions which completely surround 
and infiltrate the lung. The latter is completely adherent, airless, in a 
condition of cirrhosis, traversed by bands of fibroid tissue, and occupying a 
position at the posterior aspect of the chest in contact with the spine. In 
other cases there may be found adhesions connecting both lungs with the 
chest wall and diaphragm, and on cutting through the lungs they appear to 
be riddled with cavities, which are in reality dilated bronchial tubes. The 
relation between empyemas and tuberculosis is interesting and important. It 
is believed by some that the subjects of chronic empyemas are apt to become 
tubercular ; in other words, patients who suffer from a chronic empyema are 
likely to die of phthisis. We do not think, at least as far as our experience 
goes, that there is any post-mortem evidence to support this. That chronic 
pneumonia may terminate in tuberculosis by the mediastinal glands becoming 
caseous is an almost every-day experience, but this certainly does not apply 
to empyema. Barlow and Parker, however, state that they have met with 
cases where they believed a tuberculosis was secondary to a chronic empyema. 
Localised collections of pus may sometimes be found in connection with 
chronic tuberculosis, but in these cases the pus is apparently secondary to the 
tubercular process. 

Suppurative or simple pericarditis may take place by extension of the 
inflammation from the pleura. 

Treatme?it. — In the early stages of dry pleurisy, where the pain is severest, 
the child is necessarily placed in bed, small doses of an anodyne being given, 
and hot applications applied to the chest. Small doses of opiates relieve the 



Treatment of Pleurisy and Empyema 381 

pain best, such as Dover's powder or 2 V~A grain of morphia given sub- 
cutaneously ; the latter may be administered to children over four years, but 
not to infants. Hot poultices may be used with less fear than in pneumonia 
where much lung is involved. Strapping the chest on the affected side with 
strips of belladonna plaster is often very useful. 

The natural course of a dry pleurisy is towards recovery, the inflamma- 
tory condition of the pleura subsiding, the lymph effused being organised, 
and the lung becoming adherent to the chest wall. The adhesions thus 
formed differ very much in their firmness and strength, the lung being 
perhaps only loosely attached to the parietes, so that its movements are only 
slightly if at all impaired, or firmly attached by thick leathery adhesions, 
so that it cannot be torn away without damage. In the latter case the ad- 
hesions are extensive, the movements of the lung are impaired, it never 
properly empties itself of air, and it is in consequence always more or less 
in a congested or cedematous condition, and possibly becomes infiltrated with 
fibroid tissue while the bronchial tubes become dilated. Such cases are 
probably the result of chronic or subacute pleurisy ; the chest may also con- 
tract and fall in. When an effusion of fluid has occurred, in the vast 
majority of cases reabsorption takes place after the inflammatory condition 
of the pleura has subsided, and the tension of blood in the vessels has become 
reduced to normal. Life, however, may be threatened from the excess of fluid 
thrown out ; under these circumstances nearly the whole of the blood in the 
body is passing through the sound lung ; it is consequently intensely con- 
gested, and may become cedematous, Moreover, the right side of the heart 
is over-distended, and as a consequence sudden death is apt to ensue. For 
this reason no time should be lost, if the dyspnoea and distress become great, 
in relieving the chest by the withdrawal of some of the effused fluid. On the 
other hand, the mere presence of fluid in the chest, if there are no signs of 
distress, does not necessitate operative interference, as in the great majority 
of cases absorption takes place in the course of a few days or a week. Opera- 
tive interference, therefore, is called for in all cases where there is dyspnoea 
or orthopncea when lying quietly in bed, or where there is much displacement 
of the heart. In those chronic cases where the fluid is not absorbed or is not 
diminishing in quantity after the lapse of a few weeks, the serum may be 
removed from the chest by means either of the aspirator or by trocar and 
cannula, the small ones introduced by Dr. Southey for the removal of the 
fluid in ascites answering very well. Whatever method is selected, the fluid 
should be removed slowly, and there is no necessity to remove all that can 
be aspirated. Too rapid aspiration of the fluid is apt to lead to bleeding 
into the chest from rupture of some of the capillary vessels, and may possibly 
cause emphysema of the lung on account of one part of the lung expanding 
faster than the other. On the whole, we believe the best results are obtained 
by the use of Southey's trocar and cannula. One of these may be introduced 
without difficulty and without pain if local anaesthesia be produced, a piece of 
fine india-rubber tube attached, and the fluid allowed slowly to drain away 
for a couple of hours or so, 10 to 20 ozs. being thus withdrawn ; if neces- 
sary two cannula; can be inserted. In those cases where the dyspnoea 
is extreme, relief is more quickly obtained by aspiration. It may not im- 
probably happen that the pleural cavity in part fills up again and a second 



382 Diseases of the Respiratory Apparatus 

or a third removal be required. In the less acute cases, where there is no 
urgency and no removal is attempted, the child should be confined to bed in 
a warm room and carefully protected from cold. It may be doubted if any 
drug materially aids the reabsorption of the effused fluid, though the usual 
treatment in such cases — namely, giving iodide of potassium internally and 
painting liniment of iodine mixed with an equal quantity of glycerine exter- 
nally — appears to be useful. The lin. iodi by itself requires using with care, 
especially in young or weakly children. 

The natural cause of an empyema differs from that of a simple serous 
effusion. In a minority of cases, especially where the empyema is small 
and confined by adhesions, it may dry up, and the inspissated pus in time 
become cretaceous. But this event can hardly be expected, and should it 
take place, especially if the empyema be a large one. the result, accompanied 
as it is by retraction of the chest and compression of the lung, is anything 
but satisfactory. The presence of pus in the chest is inconsistent with good 
health, to say nothing of the risks the patients run of its burrowing in various 
directions. The child with a chronic undrained empyema probably suffers 
from hectic fever, is anaemic and sallow, the skin becomes rough, the fingers 
clubbed, and the child emaciates. Various other results may follow : the 
pus may find its way through the intercostals, and point in the fourth or 
fifth space, it may then gradually undermine the skin and a chronic 
discharge take place. It may open through the lung into a bronchial tube 
and be gradually coughed up ; in this way recovery may eventually take 
place, though the process is a slow one ; or an abscess or abscesses may 
form in the lung. An empyema on the right side may, either by con- 
tiguity or by opening through the diaphragm, give rise to an abscess in the 
liver. It may open into the abdomen by finding its way through the diaphragm, 
and set up peritonitis. The pus may burrow any distance, opening through 
the abdominal walls or simulating a lumbar abscess. 

Directly a diagnosis of pus in the chest is made, arrangements should be 
made to evacuate it, and this in the vast majority of cases should be by free 
incision and drainage. Aspiration may be tried once or twice in local 
empyemata, especially in infants and small children ; but it is only in the 
minority of cases that it will succeed, as the cavity usually fills up again 
and separates the parts which should be kept in contact if a cure is to result. 

The surgical treatment of suppuration within the pleural cavity is based 
on the ordinary principles guiding us in the management of abscesses else- 
where. Hence, although it occasionally happens that pleural abscesses dry 
tip and do not discharge at all, or discharge through the lung or elsewhere 
and then heal, none of these possibilities should be looked for, and the treat- 
ment practically resolves itself into tapping and free incision. 

Tapping an empyema with a simple trocar and allowing the fluid to drain 
away through a tube into an antiseptic lotion is a mode of treatment that 
is successful in certain cases, but is open to several objections. The cases 
for which it is suitable are those where the empyema is recent, of small size, 
contains no masses of lymph or caseous material, and where the lung is not 
bound down by firm adhesions but is ready to expand on removal of the com- 
pressing fluid ; further, it is important for the successful employment of this 
plan that the pus be contained in one cavity only and not be loculaied. The 



Treatment of Pleurisy and Empyema 383 

dangers of tapping are the risk of wounding the lung by thrusting the trocar 
too far inwards on the one hand, and on the other the possibility of pushing 
the thickened pleura or a layer of lymph before the trocar so that the 
abscess cavity is not opened. There is also the likelihood of the cannula 
becoming blocked with lymph or caseous material, and of incomplete 
emptying of the cavity because it is loculated or because the lung cannot 
re-expand. 

Aspiration is open to the same objections, with the additional one that 
if too powerful suction is employed there is likely to be bleeding from the 
surface of the lung or the pleura, and the cavity may become partially filled 
with clot which readily decomposes. 

The difficulty of emptying the cavity when the lung cannot re- expand has 
been met by Mr. R. W. Parker by- the plan of injecting aseptic air into the 
pleura to replace the pus as it flows away, or lotions may be used with the 
same object ; but the plan has not met, and is not likely to meet, with general 
approval. Aspiration, then, should be employed for small, single, recent 
empyemata, and in some few of such cases after one or two tappings the pus 
will cease to be secreted. Should there be chronic disease of the lung, 
caseous material, glandular or other, or disease of the ribs or spine, since the 
source of irritation remains, pus formation will go on and aspiration cannot 
be sufficient. Failing, then, tapping or aspiration, the remaining resource 
is free incision and drainage of the abscess. The general plan of operation 
may be described first, and certain special points alluded to afterwards. 

The incision should be an inch or more in length, and should be made 
along the lower margin of the space selected, so as to avoid injury to the 
intercostal vessels. The tissues should be gradually cut through until the 
pleura is reached, all bleeding being arrested before the pleura is opened. 
If the membrane is not much thickened, a sharp director may be thrust 
through it and used as a guide for the knife ; if, however, it is very tough 
and thick, as may be the case if the disease is of long standing, it is better to 
incise it at once with the knife. As soon as the cavity is reached a pair of 
dressing or sinus forceps should be passed in, opened, and the pus allowed 
to escape freely. The drainage tube is then to be inserted and secured by 
a thread round the chest unless a special tube is employed. Possibly the 
dressings will be soaked and require changing in a few hours ; if, however, 
the cavity is fairly emptied and thick wood-wool pads are employed, this is 
not likely to be the case. 

The special points to be considered are the position of the incision, the 
drainage tube, the management of adhesions, and the washing out of the chest. 

First, then, the position of the incision. Where the empyema is local the 
incision must of course be made over it, and the lowest convenient spot for 
drainage should be chosen. Where the whole pleural cavity is filled with 
pus a difference of opinion exists as to the most suitable spot for the opening. 
Mr. Marshall advocated an incision in the front of the chest, others prefer 
the axilla. W T e think, however, on the whole, the best place is just behind 
and below the angle of the scapula in the eighth interspace — this spot 
affords good drainage when the patient lies on his back or side ; it is not 
quite so convenient for dressing, but it is nearly at the lowest point of the 
cavity, yet not so low as to risk injury to the diaphragm, which is liable to be 



384 Diseases of the Respiratory Apparatus 

drawn up to take the place of the shrunken lung. 1 Unless the incision is 
made too far back there is no great thickness of muscle to cut through. 

As to drainage, though in some cases where the chest is very full of 
fluid the intercostal spaces may be widened and bulging, yet much more often 
this is not so, and the ribs are so close together that it is difficult to get 
a tube into the chest, and when inserted it is liable to be nipped by pressure 
of the ribs. In such cases the ribs should be prised apart with dressing 
forceps, and a rigid tube, such as a silver or vulcanite tracheotomy tube, 
employed, or a piece of rib should be excised, which is a far better plan. 
The tube should not project far into the pleural cavity, but only just enough 
to be clear of the thickened pleura, otherwise it will fail to drain the cavity, 
and may be blocked by pressure against the lung. A double tube, or two 
pieces of tubing fixed together side by side (Battams), are preferred by some 
surgeons ; the plan is useful if it is intended to wash out the chest, but in 
many cases it is open to the objection given above. 

After opening the chest a finger should be passed in if possible to 
ascertain the size of the cavity and to break down any adhesions shutting in 
localised collections of pus, 2 as well as to remove any masses of lymph or 
solid material in the cavity. If the pus is foul or thick and flaky, as large a 
tube as possible should be put in, and all solid and offensive matter care- 
fully removed after resection of a portion of a rib. Should any bleeding 
occur from the intercostal vessels, they may be picked up or secured by a 
catgut ligature passed round the rib including the vessel ; this is easily done 
with an aneurism needle. Bleeding from the granulating surface of the pleura 
after exploration soon ceases of itself, but all clots should be washed out. 

During the operation careful watch must be kept by the anaesthetist that 
the child does not suffer from having to lie upon the sound side, and at any 
sign of failing pulse or respiration the child must be turned upon its back or 
towards the affected side. The after-treatment of empyema consists in 
keeping the cavity aseptic and well-drained ; obstruction of the tube is most 
likely to be due to flakes of lymph or to slipping of the tube if a rigid one is 
used, to nipping of the tube by the ribs if rubber is employed. As regards 
washing out the chest it must be remembered that there is a certain amount 
of danger in it ; cases of sudden death during the process have several times 
been recorded, possibly from irritation of cardiac nerves in the wall of the 
cavity, or from sudden dyspnoea ; this risk should deter us from washing 
out an empyema unless the discharge continues to be foul, and it should 
lead to caution and the avoidance of any distension of the cavity or the use 
of irritant lotions even in such cases. In free incision of the chest the opening- 
is of course large enough to admit air readily, hence there is no obstacle to 
complete emptying of the cavity. The tube should not be left out until the 
discharge has nearly or quite ceased, and exploration with a probe has shown 
that the cavity is filled up ; often, though there is but little discharge, a good- 
sized cavity or a long sinus remains, and if the external wound is allowed to> 
close, fresh collections of pus will take place. In a certain number of cases 

1 The objection that an empyema usually heals up at the back first, and that therefore 
a cavity is likely to remain unclosed in front, has not in our experience proved a valid 
objection to the posterior incision. 

2 Dr. Fagge states that loculation is very rarely found post mortem. 



Empyema 



385 



the empyema will be pointing externally when the case is first seen ; such 
pointing most commonly occurs in the front of the chest from the second to 
the fifth space, the matter sometimes pushing forward and pointing through 
the mamma. If the skin is already thinned the pus should be let out at this 
spot and the case managed as usual ; if, however, the cavity does not drain 
freely, a long probe should be passed through the anterior orifice, and cut 
down upon at a more dependent spot, and a drainage tube inserted there. 
While admitting that the successful management of empyema is not simply a 
question of drainage as in other abscesses, we think a dependent opening is 
a highly important matter. A free outlet is absolutely essential. 

Sometimes the pressure of 
the drainage tube causes ulcera- 
tion of one of the ribs ; this is, 
however, a matter of little im- 
portance, since the rib usually 
recovers after removal of the 
tube. 

In a certain proportion of 
cases, after drainage of the em- 
pyema, the cavity does not 
become obliterated, but remains 
as a pus-secreting sac ; this is 
due either to imperfect expan- 
sion of the lung or insufficient 
compensatory falling in of the 
chest wall. Under such con- 
ditions the discharge may go 
on indefinitely and cause larda- 
ceous disease and hectic fever ; 
it is then necessary to find other 
means of allowing the surfaces 
of the abscess sac to come 
together. For this purpose re- 
section of one or more ribs (Est- 
lander's operation : ) has been 
devised. Although in children, 
from the softness and flexibility 
of the ribs and spine, the chest 
generally falls in readily, this is 

by no means always the case, and the operation should be done as soon as it 
is clear that progress is not being made or the child's health is failing. 
Where there is an insufficient opening for drainage, it is also necessary in 
some cases to provide a larger orifice by removal of part of a rib ; and, 
indeed, it is a good practice to excise a portion of rib in all cases where the 
child is not so feeble as to make even this slight addition to the severity of 
the operation undesirable. The operation is a simple one ; to remove a 
single rib, the lowest one in the cavity should be chosen, usually the seventh 

1 Estlander's operation is strictly the removal of a sufficient part of the chest wall to 
allow of complete collapse. 

C C 




Fig. 73. — Deformity of Chest due to Empyema. 



386 Diseases of the Respiratory Apparatus 

or eighth. An incision is made along it down to the bone, the periosteum is 
readily peeled back with a raspatory, and about an inch or more of the rib is 
cut out with bone forceps ; the periosteum and pleura are then incised 
parallel with and avoiding the intercostal vessels ; if the artery is wounded, 
however, it is easily secured now that the rib is gone. When the resection 
is done to allow collapse of the chest wall, from two to five ribs may have to 
be resected, two or three inches of bone being taken from each ; in such 
case a quadrilateral flap of the soft parts should be turned forward and the 
ribs removed one after the other. Though it is perhaps better in such cases 
to remove the bones subperiosteal^, the periosteum should be cut away 
before closing the wound, otherwise it often happens that ossification 
rapidly takes place and fills up the gap in the chest wall, and so prevents the 
desired collapse. We have sometimes found the intercostal vessels ob- 
literated in these cases, and there has been no arterial bleeding at all. 
Marshall has divided the costal cartilages subcutaneously with the same 
object, but resection is the more complete operation, and it sounds and 
looks more formidable than it is. The subsequent management of the 
wound requires no description. Unless an empyema speedily recovers, 
more or less retraction of the side necessarily results, and from this a 
lateral, or rather, as Lane has pointed out, a true rotato-lateral curvature of 
the spine follows : this of course is largely irremediable, but some improve- 
ment may be obtained by treatment {vide Lateral Curvature). 
(Fig. 73-) 

Inasmuch as the ribs are less yielding near the angles, it is better to 
remove the bone as far back as possible up to the edge of the erector spinae. 
We have tried osteotomy of the rib at the posterior part at the same time as 
resection to allow more complete falling in of the chest wall, but found little 
was to be gained by this means, since the rib is held firmly in place by the 
surrounding soft parts. 

Spasmodic Asthma 

Spasmodic Asthma is a disease which perhaps ought to be classed with 
the ' neuroses,' but on account of its frequent association with bronchial 
catarrh and emphysema it is most convenient to discuss it under respiratory 
diseases. 'Asthma' or a condition of urgent dyspnoea occurs in renal 
disease, cardiac failure, pressure on the air-passages by tumours, and in 
hysteria ; but in these instances the dyspnoea is secondary, and need not be 
discussed here. The term asthma is popularly applied to chronic bronchitis, 
but it is needless to say that the dyspnoea of bronchitis is caused by bronchial 
tubes choked by thick mucus, and not by spasm of the bronchial muscles, as 
it presumably is in asthma. 

True asthma appears to be related to ' cyclic ' vomiting, recurring head- 
aches, and epilepsy, and is due to functional disturbance of the respiratory 
centre brought about by some reflex irritation. It is a common disease in 
children, commencing in some instances in the second or third year, but 
perhaps more frequently later. In some respects it resembles laryngismus, 
but as far as we know children who suffer from laryngismus do not exhibit 
any tendency to asthma. The disease is frequently hereditary, or at least 
runs in families. 



Spasmodic Asthma 387 

The exciting causes cf an attack are various, the commonest being a 
bronchial catarrh or bronchitis, nasal catarrh, especially where there are also 
' post nasal adenoids,' ' hay fever,' undigested food in the alimentary canal. 
The acute attack usually begins in the small hours of the morning, the child 
being seized with dyspnoea ; it sits up in bed and fights for its breath, the 
respirations are quick, the alse nasi work, and the face is a dusky colour and 
the lips cyanosed. On listening to the chest, hissing and rhonchi are heard all 
over. The attack may last for several hours, then the dyspnoea becomes less 
urgent and a free secretion of mucus takes place. While such is the course 
of a typical uncomplicated attack, we constantly find there is more or less 
bronchitis associated with it. Before the attack develops there is for some 
hours or days a certain wheeziness rioted, and an acute exacerbation occurs 
at night time ; next day there is no distress, but rhonchus can be heard all 
over the chest, and any exertion causes dyspnoea. The child is a long time 
before its chest is normal, and then perhaps exposure to cold brings on an- 
other bronchial catarrh and another attack of asthma. As time goes on if 
the attacks follow one another with great frequency, the lungs become 
emphysematous and the chest constricted. Asthma is not dangerous to life, 
there does not seem to be any special tendency to tuberculosis in those who 
suffer, but the prognosis as far as the attacks are concerned is uncertain. 

With regard to the treatment, diet is of a great importance, as there can 
be no doubt that indigestion aggravates or in some cases starts the attacks. 
As a general rule the child should live largely on eggs, vegetables and milk, 
using meat sparingly ; but fish, chicken and soup may be allowed. Alcohol 
and all highly seasoned foods should be avoided. Care should be taken with 
regard to the clothing ; it is especially important that the undergarments should 
be all wool so as to avoid chills. There must be no ' coddling ' at one time and 
carelessness as regards colds at another time. Plenty of fresh air whenever 
possible, and no steamy, over-heated rooms during a bronchial attack. 
Climate is of great importance, but it is not easy to say what climate will suit. 
Some do best in climates like Falmouth, Sidmouth, or the South of France, 
during the winter, and Buxton, Malvern — in summer — or high lands which 
are breezy and bracing. Between the attacks the best medicine is cod liver oil 
in some form ; both arsenic and iodide of potassium may be tried and are 
sometimes of benefit. Carlsbad salts and citrate of lithia and potash are 
useful in aperient doses from time to time. During the attack the fumes of 
burning powder containing stramonium, nitre and tobacco unquestionably 
relieve the majority of cases. The drug which most quickly relieves is 
morphia subcutaneously, -^ to £ of a grain being the usual dose for a child 
of seven to ten years of age. Chloral is useful but acts more slowly. 

Nasal adenoids and hypertrophied tonsils should be removed, as they 
aggravate the attacks by obstructing the air passages, and they are moveover 
a source of discomfort to the patient. We doubt very much if spasmodic 
asthma is ever cured by their removal, but the general health and comfort 
of the child is improved. 

Diseases of the Bronchial Glands 

The tracheo-bronchial glands are situated in the middle mediastinum 
in close relationship with the trachea and bronchi ; they are some ten to 



388 Diseases of the Respiratory Apparatus 

twelve in number, and arc arranged in three groups ; one set surrounds the 
trachea, another group is situated at the bifurcation, and a third around the 
right and left bronchi. The pulmonary glands are situated at the root of 
the lung and accompany the bronchi into the substance of the lung. These 
glands receive the lymphatics of the lungs and bronchi, and like other 
lymphatic glands readily become inflamed and swollen during attacks of 
bronchitis and broncho-pneumonia, especially after measles and whooping 
cough, and are apt to remain chronically enlarged, and further to become 
caseous and to suppurate. During this inflammatory process more or 
less thickening and matting often takes place in surrounding parts, so that 
the glands may become adherent to the trachea or bronchi or oesophagus. 
The glands and connective tissue in the 'anterior and posterior mediastinum 
may also become affected, so that the antero-internal edges of the lungs 
and the whole contents of the mediastinum may become thickened and 
matted together. 

Caseation of the mediastinal glands is exceedingly common in children, 
and they may be found in this condition in the bodies of children dying of 
various diseases, but they are almost universally caseous in those dying of 
pulmonary tuberculosis or chronic catarrhal pneumonia. In many cases 
of acute or chronic tuberculosis it is clear that the disease in the glands is 
older than the tubercle in the lungs, and has spread from the former to the 
latter. In such cases the glands have become enlarged secondarily to some 
bronchitis or pneumonia, have undergone caseation, and the lungs have been 
infected in consequence of caseating bronchial or pulmonary glands, the 
tubercular disease spreading into the lungs from the root. (See Tuber- 
culosis, p. 230.) 

Symptoms. — In the large majority of cases there are no distinctive 
symptoms of caseating mediastinal glands, and per se they are not more 
likely to give rise to symptoms than caseating glands in the neck ; but, inas- 
much as they are so frequently associated with early or chronic tuberculosis 
of the lungs, the subjects of them are hardly likely to present the appearances 
of health. Not infrequently, however, they are found unexpectedly in the 
bodies of children dying of other diseases. With regard to physical signs, it 
must be clear from a consideration of the anatomy of the mediastinum that 
the glands lie too deeply to be detected by percussion unless they are 
enormously enlarged ; this may take place in sarcomatous enlargement, but 
rarely in tuberculosis. It has been asserted that when enlarged they can be 
detected by a diminished resonance in the interscapular region, correspond- 
ing to the first three dorsal vertebrae ; but, inasmuch as the thick posterior 
edges of the lungs, besides the aorta, oesophagus, and a mass of muscle, 
intervene between the glands and the surface, it is certain that the enlarge- 
ment must be very considerable to modify the percussion note in this 
position. Enlarged glands are more likely to modify the resonance behind 
the upper part of the sternum and adjacent cartilages, but in infants and 
young children the anterior mediastinum is occupied by the thymus, which 
would mask any enlargement of the lymphatic glands ; and in older 
children, where the thymus is small, lymphatic glands must be very much 
enlarged to come to the surface and give rise to any dulness, covered as 
they are by the anterior edges of the lungs. Error may easily arise from a 



Diseases of the Bronchial Glands 



389 



dulness due to a past pleurisy and consequent adhesion along the anterior 
edges of the lungs. If the results of percussion are uncertain, those derived 
from auscultation are necessarily more so, except in considerable enlarge- 
ment of glands. Of the pressure signs, the most reliable is weak breathing 
in one of the lungs in consequence of pressure on the right or left bronchus ; 
this sign is of undoubted value, but as there is usually some tubercular lesion 
in the lungs, this symptom may readily be masked. Attacks of paroxysmal 
dyspnoea, and cough with stridulous breathing, may also be present on 
account of the nerves being involved. Swelling of the face and dis- 
tension of the jugulars have also been described, but these are far more 




Fig. 74.— Section through a large mass of cheesy glands at the bifurcation of the trachea, and 
extending along the bronchi into the lung. Two of the glands are beginning to show signs 
of softening at their centres. (After W. P. Northrup, M.D.) 

frequently due to constant coughing than to any pressure on the large veins 
in the chest. A caseous gland not infrequently becomes adherent to the 
trachea or one of the bronchi, and ulcerates into it, and caseous matter may 
be coughed up ; in a few instances it has happened that this takes place 
suddenly and death results from plugging of the windpipe. In other 
instances the glands may form an abscess which points in one of the inter- 
costal spaces close to the sternum, as in a case under the care of Dr. 
Eustace Smith, or may open into the oesophagus. In one of our own cases a 
mediastinal abscess pointed near the left edge of the sternum, low down. 



390 Diseases of the Respiratory Apparatus 

The pulmonary glands which accompany the small bronchial glands into 
the lungs may become caseous, soften, and form cavities, more especially in 
the lower lobes. It must be acknowledged that caseous glands can rarely 
be diagnosed during life with anything like certainty, partly on account of 
their lying deeply, and partly from the fact that they are so commonly asso- 
ciated with chronic lung disease. They rarely attain any large size, and 
consequently do not modify the percussion note or press on the veins, bronchi, 
or nerves. 

When, however, the mediastinal glands become the seat of a new growth, 
such as lymphadenoma, the case is different ; they may become enormously 
enlarged, surrounding the veins and bronchi, giving rise to marked dulness 
over the sternum and adjoining rib cartilages, and pressure signs from 
involving the vessels. Attacks of paroxysmal breathing are common on 
account of pressure on the recurrent laryngeal and other nerves. The course 
of the disease usually extends over a few months only, the patient getting 
progressively worse. Among the early symptoms will usually be those of 
disturbed innervation. There are attacks of paroxysmal cough, with a metal- 
lic ring and stridulous breathing and orthopncea, so that the child has to 
be propped up to get its breath ; in the later stages the distress is often very 
great. The voice is altered, perhaps reduced to a whisper. The return of 
blood to the chest may be interfered with on account of the superior vena 
cava being compressed, giving rise to a distension of the jugular or axillary 
veins and swelling of the face or arms. Fluid may be present in one or both 
pleural cavities from pressure on the azygos veins. If the tumour is of any 
size, there will be dulness over the sternum or in the adjoining region, parti- 
cularly to the left edge of the sternum in the upper intercostal spaces. In- 
tense bronchial breathing may be heard here. Moreover, the lung may be 
pushed to the left by the encroachment of the tumour, which may bulge 
forward the sternum and ribs. 



Chronic Tuberculosis of the Lungs 

Infancy and Early Childhood. — No age is free from liability to be affected 
with tubercle ; thus Demme has found tubercular disease of the intestine in 
an infant of twenty-nine days. 

Tubercular disease is not common in infants of a few months old ; at 
this period gastro-intestinal atrophy is exceedingly common, and is liable 
to be mistaken for tubercular disease on account of the wasting which takes 
place. Tuberculosis in young children rarely begins as does the phthisis of 
adults by a growth of tubercle and a condensation at the apices of the lungs, 
and a gradual extension downwards taking place, but is apt to be far more 
widespread in its distribution both in the lungs and in the body. It is there- 
fore far more difficult to diagnose by means of physical signs which are less 
distinctive than are those of adults. It is needless to say that the same 
general appearances are found in the bodies of children as in adults dying of 
tuberculosis — grey tubercle, caseous masses, iron-grey infiltration and fibroid 
tissue in excessive quantity, and irregular cavities. The distribution, however, 
usually differs, one of the chief differences being that in adults the tubercular 
processes appear to have a special affinity for the apices ; in early childhood 



Tuberculosis of the Lungs 391 

there is no such predilection, the hilus of the lung or base being frequently 
affected before the apex. The bronchial glands are almost constantly 
found caseous, with also the small pulmonary glands which accompany the 
bronchi, the latter suppurating and forming small cavities near the root of 
the lungs. In this way a tuberculosis may spread into the lungs from the 
hilus. Not infrequently one or both bases are semi-solid from caseating 
pneumonia with ragged cavities, at other times a similar state of things is 
found at the apex. In other cases both lungs are stuffed with clusters of 
grey or yellow tubercles surrounding the terminal bronchi. There may be 
tubercle on the surface of the pleura, with more or less pleurisy or small 
local empyemas. The abdominal organs are exceedingly apt to be affected : 
cheesy masses are frequently found in the liver, spleen and kidneys ; cheesy 
mesenteric glands and ulceration of the intestines are very common in cases 
of general tuberculosis. Tubercles are not infrequently found on the peri- 
toneum and other serous membranes, as the pleura and meninges of the 
brain. Tubercular disease of bone may be associated with a general dis- 
tribution of tubercle throughout the body. (See Tuberculosis, p. 230.) 

Symptoms. — If the diagnosis of phthisis in the early stages is difficult in 
adults, when it is possible to carefully auscultate and percuss the apices 
of the lungs, examine the sputa for bacilli, and cross-question the patient 
concerning the symptoms presented, it is necessarily much more difficult in 
the infant or young child, where the symptoms are rarely definite and where 
the lesions are so widely spread throughout the body. The younger the 
subject the more likely are the symptoms to be wanting in distinctiveness 
and the diagnosis to be consequently difficult, frequently wasting and a 
family history of tuberculosis being nearly all there is to go by. The tem- 
perature is usually hectic, normal, or perhaps subnormal in the morning, and 
reaching 102 or 103 in the evening, though this may be reversed. There 
may be diarrhcea without apparent cause, and various dyspeptic troubles ; 
cough, though this may be absent ; perhaps enlargement of some external 
glands. An examination of the lungs may reveal very little, perhaps some 
want of resonance over the base or apex or in the interscapular region or 
axilla, with some ringing consonant rales or crepitation. There is progressive 
wasting, which in a child of over a year or eighteen months is more sus- 
picious than in an infant a few months old, where wasting is more often 
due to chronic intestinal catarrh than to tuberculosis. In those cases where 
wasting and hectic follow measles, whooping cough, bronchitis, or broncho- 
pneumonia, there is a strong suspicion of tuberculosis, even though there 
may have been a period of comparative health intervening between the 
acute attack and the hectic supervening ; a family history of phthisis would 
make the case look still more threatening. In the later stages the sym- 
ptoms become more decisive. The hectic continues, the wasting is pro- 
gressive, the cough is troublesome, the diarrhcea perhaps is still present, 
parasitic stomatitis makes its appearance, the feet, hands, and face become 
cedematous, and the child is anaemic and very weak. Examination of 
the chest will now show some marked dulness or loss of resonance over 
some portion of lung, apex or base, with bronchial breathing and sharp con- 
sonating rales ; often one is surprised to find how little can be detected 
in the chest, even when it is evident that the child is far advanced in 



39 2 Diseases of the Respiratory Apparatus 

tubercular disease. The typical signs of a cavity can rarely be elicited, 
inasmuch as the cavities in the lungs of infants and young children are not 
often larger than marbles or walnuts ; most frequently they have irregular 
and ragged walls. A cracked-pot sound may sometimes be elicited in front, 
but on account of the yielding nature of the chest walls in an infant it is 
of no diagnostic value as regards a cavity. 

Diagnosis. — Whenever wasting occurs as a prominent symptom during 
infancy and childhood, tuberculosis is certain to be thought of; wasting 
occurs in all dyspeptic diseases during infancy, and it may simulate the 
wasting of tuberculosis when it occurs in connection with empyema or 
broncho-pneumonia in young children. An empyema may readily be mis- 
taken for tuberculosis of the lung if a careful examination of the lungs is 
not made, aided if necessary by an exploratory puncture, as there is wasting, 
hectic, and cough. The difficulty in deciding may be great without explora- 
tion if the empyema is localised or there is more than one. A chronic 
effusion in the pericardium may be mistaken for tubercular disease. It is 
often difficult in cases of chronic broncho-pneumonia, the chronic condition 
following an acute attack, to decide if a tubercular process is going on. 
There may be wasting and hectic, and yet after some weeks the temperature 
will gradually fall, the lung clear up, and the child perfectly recover. In 
most cases only the progress of the case will decide the question. 

Older Children. — After the age of six years — in other words, after the 
commencement of the second dentition — chronic tuberculosis much more 
frequently resembles the chronic phthisis of adults than it does before this 
era. As the child gets older the resemblance becomes still more close. 
Children before this age rarely suffer from chronic tuberculosis of the adult type. 
The early symptoms are those of cough, loss of appetite, diarrhoea, wasting, 
night sweats, and hectic ; progressive weakness ; the symptom which we miss 
for the most part is haemoptysis, which, though sometimes present, is much 
more frequently absent in children than in adults, and less blood is expectorated. 
An examination of the chest may perhaps disclose some loss of resonance at 
one apex (usually the right), with perhaps some rhonchus or moist sounds, 
or there may be no loss of resonance, only the signs of a chronic or subacute 
bronchial catarrh localised in the apex of a lung ; or there may be impaired 
resonance only, due to the presence of a thickened pleura and- adherent 
lung. In this stage children perhaps more often than adults improve under 
treatment and a careful hygiene, and may be restored to perfect health ; there 
is abundant evidence to demonstrate this. If the disease progresses the 
hectic and wasting continue, the child becomes pallid and weak, the diar- 
rhoea frequent and troublesome, especially following meals ; the physical 
signs show an extended area of lung involved, the tubercular infiltration 
travelling from the apex towards the base, and giving rise to caseous degene- 
ration, fibroid changes, and cavitation. The progress of such cases is apt 
to be more rapid than it is in adults, a fatal result occurring in four to 
six months. In the last stages the emaciation is extreme, the feet ©edematous, 
bed sores are apt to form, and while the patient may linger for a while if no 
intercurrent affection brings the end quickly, it must be borne in mind that 
such cases are exceedingly apt to be brought to a conclusion by tubercular 
meningitis in any stage early or late. The abdominal organs are also apt to 



Tuberculosis of the Lungs 393 

join in a more extensive spreading of tubercle than is the case later in life ; 
mesenteric disease, extensive ulceration of bowels, peritonitis subacute 
or acute, are apt to be present, and necessarily influence the course of the 
disease. Haemoptysis, which may be fatal almost immediately, occa- 
sionally occurs ; in other cases blood may be expectorated in considerable 
quantities. 

Sometimes an acute phthisis takes place without miliary tuberculosis 
being present ; the tubercular process taking the form of clusters of grey 
tubercle surrounding the bronchi, the process beginning at the apex and 
travelling towards the base, the symptoms being those of a rapid phthisis, 
perhaps extending over a month or two. 

On the other hand, a fibroid phthisis essentially chronic in its course 
may take place, appearing at times to be stationary, or the patient undergoes 
considerable improvement. In these cases there is much fibroid change and 
iron-grey induration of lung with retraction of chest. The physical signs 
develop slowly, there is dulness of an apex, which gradually becomes almost 
absolute, intense bronchial breathing, consonant rales and gradual retraction 
of the affected side. The child may fatten and appear to flourish, and present 
a normal temperature, but it is easily exhausted, suffers from dyspnoea on 
exertion, its face and lips are turgid, and the fingers become clubbed. In 
a few cases there is haemoptysis, but this is the exception. It is possible 
that the process may become arrested, the lung being converted into fibroid 
tissue. In the majority of cases the disease is progressive, and the opposite 
apex becomes affected. The whole course may extend over several years, 
unless bronchitis or some other intercurrent disease supervenes. 

The principal clinical differences between chronic phthisis in older chil- 
dren and adults may be summed up as follows : 

1. Frequency with which children in the first stage recover. 

2. Frequency with which the disease is brought to an abrupt termination 
by some acute affection, as tubercular meningitis, pleurisy, peritonitis, or 
acute miliary tuberculosis. 

3. Comparative rarity of haemoptysis in the early stages and of laryngitis 
in the latter stages. 

4. Frequency of complication with abdominal tuberculosis. 

5. Comparative rarity as compared with that of adults of extensive cavities 
in the lungs. 

6. Rarity with which the larynx is affected with tuberculosis. 

The post-mortem appearances are mostly similar to those found under 
similar circumstances in adults. Irregular ragged cavities, varying in size 
from a hazel nut to a walnut, most numerous in the upper lobes, with cheesy 
masses and fibroid indurations ; the same condition in the lower lobes in 
an earlier stage, with more or less crepitant lung. As a rule there is not 
much grey tubercle, but caseous masses, sometimes associated with peri- 
bronchial grey or yellow tubercles. There are not often cavities of large 
size, but these occur at times ; in one case, in a boy of eight years, who had 
suffered for six months, there was a cavity in the upper two-thirds of the left 
lung as large as an adult's clenched fist. Pleurisy and small collections of 
pus are not uncommon. The bronchial glands are almost invariably en- 
larged and caseous. 



394 Diseases of the Respiratory Apparatus 

Instead of the above, especially in the more acute cases, the lungs may 
be everywhere infiltrated with clusters of peribronchial tubercles, which 
crowd the upper lobes, where ragged irregular cavitation is commencing, 
while they are more sparely scattered through the lower lobes. 

In fibroid phthisis an extensive portion of one or both lungs is cicatrised 
and solid, bands of fibrous tissue run across, there is much grey infiltration, 
dilated bronchi, caseous glands, and perhaps small ragged cavities. Other 
portions of lung are hypertrophic or emphysematous, perhaps containing 
scattered clusters of peribronchial tubercles. 

Cheesy tubercles are met with constantly in other organs than the lung, 
especially in the liver, spleen, and kidneys ; caseous mesenteric glands and 
ulceration of the intestines may also be associated with lung mischief. 

Treatment. — The treatment of enlarged and caseous glands is necessarily 
the same in large measure as that of early tuberculosis. If a child, say one 
from three to six years of age, suffers from a hacking paroxysmal cough, is 
slightly feverish at night, remains in a condition of ill-defined malaise, especi- 
ally if he has recently suffered from bronchitis, whooping cough, or measles, 
the suspicion will be raised that there is either caseation of the bronchial glands 
or an early tuberculosis of the lungs. There can be no certainty about the 
diagnosis, but if the family history points to tuberculosis there is only too 
much reason for anxiety. The indications for treatment which suggest 
themselves are to place the child under conditions in which there will be the 
least possible irritation of the lungs and bronchial tubes, and to supply him 
with nourishment in suitable quantities and in the most digestible forms. 
It is needless to say that these indications are fulfilled with difficulty or only 
partially. Residence in the smoke and dirt of large towns, or on damp 
clay subsoils, is alike bad, and if possible the child should be removed to 
some breezy moorland site or bracing seaside place. Fresh air when it can 
be taken without risk of cold is of the greatest possible advantage in bracing 
up the digestive organs. In winter, if it be impossible to seek a warmer 
climate, thoroughly warm and well-ventilated apartments free from draughts 
must be secured. A well-warmed but not ' stuffy ' house is a great advan- 
tage, as the child may in such a case have the ' run ' of the whole house 
without being exposed to cold passages and open windows. A nourishing, 
easily assimilated diet should be prescribed, a variety being introduced in 
order to tempt the capricious appetite often present. A cup of beef tea 
the last thing at night will often ease the cough and soothe the child to sleep. 

Of special medicinal treatment, cod liver oil, malt extract, mineral acids 
with cinchonine and the hypophosphites may be prescribed with advantage. 
Creasote or guaiacol is often prescribed. Counter-irritants are useful ; they 
are hardly likely to have much effect on glands which are actually caseating, 
but they undoubtedly favourably influence chronic catarrhs of the bronchial 
mucous membranes. Among the milder ones, the lin. pot. iodid. c. sapone 
may be rubbed into the chest every evening, a piece of ' swansdown ' or layer 
of cotton wool being applied. A stronger application may be made by diluting 
lin. iodi with glycerine and water (F. 27), and applying it to the sternum 
or the subclavicular region every night and covering it over with a layer of 
cotton wool. Care must be taken not to render the skin sore by applying it 
too frequently on the same spot. 



Tuberculosis of the Lungs 395 

The more urgent symptoms present when the nerves are involved by a 
mediastinal tumour — and these are often very distressing — may be relieved in 
many cases by warm applications, such as fomentations, and small doses of 
nepenthe or morphia. Relief will probably be obtained from opiates com- 
bined with ether or chloroform if the dyspncea is due to spasm. Inhalations 
of chloroform, ether, or nitrite of amyl, usually relieve. Small doses of 
morphia given subcutaneously may be tried. 

Much that has been said applies to the early stages of all forms of chronic 
tuberculosis of the lungs. It is of the greatest possible importance to recog- 
nise the disease in its early stages, when there is a fair probability that it may 
be arrested or undergo a natural cure if the conditions are favourable. To 
this end an equable temperature, a pure bracing air, protection from cold and 
damp and rapid temperature changes are of the greatest importance. The 
presence of tubercle in the lungs naturally predisposes to catarrhs and local 
pneumonias, and exposure to unfavourable conditions likely to favour their 
development is certain greatly to aggravate the disease. Great care must 
also be taken in the food which the child takes and in treating any departure 
from a healthy condition of the child's digestive system. A condition of 
catarrh of the bowels is very often present in tubercular diseases apart from 
any local lesion, and is an important factor in producing the wasting which 
accompanies tuberculosis. 



396 Diseases of the Circulatory System 



CHAPTER XVIII 

DISEASES OF THE CIRCULATORY SYSTEM 

Diseases of the Heart 

Physical Ex animation. — An examination of the heart includes an en- 
deavour to determine its position, size, and the character of the cardiac 
sounds. It is needless to say that the younger the child, the more difficult 
it is to make a satisfactory examination. The first point to determine is the 
position of the apex beat, and as this gives us important information for 
making a diagnosis, it should never be neglected. If not visible its position 
may usually be felt by laying the extended hand on the cardiac area, and 
note must be made as to whether it occupies a larger space than normal, and 
whether it is accompanied by a thrill. The usual position of the cardiac 
impulse in adults is in the fifth interspace and well within the left nipple line. 
Symington has shown, by a number of frozen sections of the thorax at dif- 
ferent ages, that during childhood the apex beat is apt to take a more 
external position as regards the nipple than in later years, a result due to 
the greater relative narrowness of the child's chest in the transverse 
diameter. As a matter of fact, it is usually well within the nipple in most 
children according to our observations, but we must not hastily come to the 
conclusion that because we may find in a given case it is actually in a line 
with the nipple that disease is present. If external in position to the nipple 
we should always be suspicious that there is an abnormal displacement of 
the heart to the left, or there is some dilatation of the left ventricle. 1 If the 
impulse is raised it would suggest that it was displaced upwards by a dis- 
tended stomach or other abdominal enlargement, or there is chronic lung 
disease of the left apex, or possibly pericardial effusion. If the impulse is 
displaced to the right there is in all probability fluid in the left pleura. 
Epigastric pulsation in a case of chronic heart disease generally means 
dilatation of the right ventricle. A heaving impulse lower than normal, the 
chest wall being lifted during systole, suggests hypertrophy of the left 
ventricle, a diffused weak impulse implies dilatation. 

In mapping out the size and position of the heart by means of percussion 
we necessarily take the ' deep dulness ' as our guide, but as the cardiac 
dulness shades away laterally into the pulmonary resonance, great care 
must be taken in the determination. Let us bear in mind that the shape 
and elasticity of the chest walls may modify the percussion note, and this is 

1 Steffen comes to the conclusion that in most children the cardiac impulse is in the 
nipple line, and in some instances one cm. external, without indicating disease. 



Diseases of the Heart — Congenital Heart Disease 397 

especially true in percussing over the lower half of the sternum. Some writers 
have laid down rules as to the limits of the cardiac dulness in children of 
various ages. We doubt very much the correctness of some of the statements 
which have been made, and we should recommend the student to bear in 
mind only the limits which he has been accustomed to observe in the wards 
of an adult hospital, but not forgetting that an extension of dulness to the left 
more than in the case of adults does not necessarily mean a pathological con- 
dition. The upper limit of the heart is the upper edge of the third left costal 
cartilage ; dulness extending higher than this suggests fluid in the pericar- 
dium, an enlarged heart, or a lesion at the left apex of the lung. The left 
border of the heart should lie within a curved line drawn from the junction 
of the third left costal cartilage with the sternum, extending downwards and 
to the left to the fifth space just within the nipple line. The right border 
corresponding to the right auricle should lie within a line drawn from the 
above point curving downwards and outwards along the right edge of the 
sternum. Inferiorly the cardiac dulness cannot be distinguished from the 
hepatic dulness. In chronic disease the chest wall is frequently bulged 
over the cardiac area, while the dull area is extended both to the left and 
right, and may even measure as much as 6 inches across from side to side. 
We will defer reference to the cardiac sounds till later. 



Congenital Heart Disease 

The different forms of malformed hearts are exceedingly numerous and 
defy any attempt at classification, but as many of these, though of great 
interest to the anatomist as illustrating the various stages of development, 
are of little practical importance to the clinician, no detailed description is 
needed here. The principal causes at work in producing these malformations 
may be classified as follows : (1) Persistence of foetal openings, more par- 
ticularly the foramen ovale, in consequence of the lungs remaining in part in 
the foetal state after birth ; there is obstruction through the lungs and over- 
filling of the right heart. (2) Endocarditis, occurring during foetal life, 
affecting the pulmonary, the tricuspid, and less often the aortic or mitral 
valves, producing stenosis at the valvular orifice, and as a secondary effect 
the persistence of the foramen ovale, or ductus arteriosus ; or the septum 
ventriculorum may remain incomplete. (3) An arrest of development at 
some period of foetal life or the results of a false step, as it were, as when 
a transposition of the aorta and pulmonary artery occurs. 

Congenital heart disease not infrequently occurs in several members of 
the same family ; in one case coming under our notice, where there were four 
children two sisters and one brother were thus affected. 

Symptoms. — Cyanosis and the presence of a bruit are the only reliable 
signs of congenital heart disease. Cyanosis is mostly, but not universally, 
present, and it varies considerably in intensity. It is most marked, and is 
sometimes only present when the infant cries, the face being dusky, the lips 
and tongue and extremities becoming of a bluish tinge. We must, however, 
bear in mind that some cyanosis may be present in prematurely born infants 
when the lungs are but partially inflated, and remain in the foetal state, and 
often atrophic and feeble infants have blue and cold hands and feet. If, 



398 Diseases of the Circulatory System 

however, the cyanosis persists for many weeks, it is probably due to mal- 
formation of the heart. In a certain proportion of cases murmurs are heard. 
These are apt to be of a rough, rasping, superficial character, and the rhythm 
is often exceedingly difficult to determine, on account of the rapid action of 
the infant's heart. The differential diagnosis is very frequently impossible, 
and only a sort of guess can be made. The position of greatest intensity 
should be determined ; but this is not always easy, as many of the murmurs 
are so loud that they are heard all over the chest. Note should be taken as 
to whether the bruit replaces or is only heard through, as it were, the heart 
sounds. A thorough examination cannot, perhaps, be made at first, as it is 
unwise to expose a weakly infant too much, and, moreover, the possibility of 
a pericardial friction sound in newly born infants must not be forgotten. 
Any external congenital malformation would suggest that the heart defect 
was the result of some arrest of development or some abnormal development 
rather than due to endocarditis. 

The prognosis is, of course, bad, but much uncertainty must necessarily 
exist, as the diagnosis of the exact form of lesion present often cannot be 
made. The more cyanosis present the worse is the prognosis, as, in infants 
at least, there is a great liability to meningeal haemorrhage taking place, 
either slowly or during a fit of crying, vomiting, or coughing. Convulsions 
may at any time supervene and quickly prove fatal. The venous state of 
the blood interferes with the secretion of the digestive juices, and the whole 
system is worked at a disadvantage. In older children the amount of hyper- 
trophy and dilatation must be taken into account in making a prognosis ; the 
larger the heart, the nearer is it to the end of its tether. The extent to which 
clubbing of the fingers is present must also be considered. 

Patent Foramen Ovale. — The foramen ovale allows of the passage of 
blood from the right to the left auricle during fcetal life (see fig. 75), but closes 
up shortly after birth if there is no obstruction to the circulation of blood 
in the pulmonary system, and consequent increased blood pressure on the 
right side of the heart. If, on the other hand, the lungs are only partially ex- 
panded, remaining in part in the fcetal condition, a portion of the blood which 
under normal conditions would enter the pulmonary circulation escapes it by 
passing directly from the right heart to the left through the foramen ovale. 
Repeated attacks of bronchitis after birth may have a similar effect in pre- 
venting the closure of the foramen ovale. The further history of such cases 
is uncertain, but there is reason to suppose that, if the child remains free 
from pulmonary trouble, the foramen ovale may close, or at least allow of 
but little mixture of the blood of the auricles, and be therefore of but slight 
detriment to the patient. It is not uncommon to meet with such cases in 
children a year or two old, who come under medical treatment for bronchitis, 
and in whom a loud systolic basic bruit is heard, which varies in intensity 
according to the amount of pulmonary trouble present. In one of our own 
cases, a child of thirteen months, there was much bronchitis, anaemia, and 
oedema ; the child recovered for a while, but died of diphtheria nine months 
later. The ftost-mortem showed the foramen ovale to be the size of a 
shilling, partly closed by membranous bands crossing it ; possibly these had 
produced the bruit heard during life. The pulmonary artery was dilated. 
An open foramen ovale is usually present in cases where there is stenosis of 



Congenital Heart Disease 



399 



the pulmonary artery or tricuspid orifice. The murmur produced by the 
passage of blood through an unclosed foramen ovale is heard best at the base 
of the heart in front, and is also heard well behind. In position the foramen 
lies at the posterior aspect of the heart, on a level with the fifth costal carti- 



Pulmonar}- Artery 
R. Auricle 



Umbilical Vein' 



Cord 



Hypogastric ) 
Artery J 




L. Auricle 



Aorta 

Ductus Venosus 



Portal Vein 



Umbilicus 



L. Iliac Artery 

R. Iliac Artery 

Internal Iliac 

J! External Iliac 



■Placenta 
Fig.. 75. — Plan of Fcetal Circulation (Gray's ' Anatomy'). 

lage, where it joins the sternum, being behind the sternum and somewhat to 
the right. Posteriorly it lies just in front of the seventh vertebra. There may 
be an open foramen and yet no bruit be heard, as, if there is no pulmonary 
obstruction, there may be little or no rush of blood through the orifice. As 
the passage of blood from auricle to auricle takes place during the auricular 



400 Diseases of the Circulatory System 

systole, presumably the bruit should be ' presystolic ' in rhythm, immediately 
preceding the first cardiac sound. It can readily be understood that it is not 
easy to distinguish between a presystolic and systolic bruit in an infant or 
young child, especially if there is some pulmonary trouble. 

It is not uncommon to find a more or less open foramen ovale in older 
children. In one of our cases, a boy of ten and a half years who suffered 
from chronic heart disease and had had several attacks of rheumatism, we 
found post mortem a large dilated heart with a much-thickened pericardium, 
an abnormally small aorta only admitting a little finger, an open foramen 
ovale, and a thickened and puckered mitral valve. 

Patent Septum Ventriculorum. — Unlike the inter-auricular partition, 
the septum between the ventricles becomes complete during fcetal life, usually 
during the third month. If, however, there is any obstruction at the pul- 
monary orifice, or any malformation which renders unequal the pressure of 
blood in the two ventricles, the ventricular septum remains incomplete and 
allows of the passage of blood from one ventricle to the other. The spot 
which remains open, or is the last to close up, is the so-called ' undefended spot ' 
at the base, where the septum intervenes between the mitral and tricuspid 
valves, and is normally the thinnest and most membranous. An incomplete 
septum is usually associated with pulmonary obstruction, or is found in 
cases where the aorta arises from both ventricles, or where there is trans- 
position of the great vessels. In some few cases it appears to be a primary 
defect arising from arrest of development or some unknown cause. In such 
cases the child may live several years, the heart becoming enlarged, more 
particularly on account of the left ventricle undergoing dilatation and hyper- 
trophy in its efforts to maintain sufficient tension in the arteries during the 
systole, while under the disadvantage of its contents being in part forced into 
the more feebly acting right ventricle. The murmur produced is loud and 
rough, replacing the first sound ; it is heard loudest over the lower part of 
the sternum, but is well conducted to the seat of cardiac impulse. It is also, 
if loud, heard both in the axilla and posteriorly. 1 

Stenosis of the Pulmonary and Tricuspid Orifices. — If an endocarditis 
occur during fcetal life, especially during the early period, it is apt to affect 
the pulmonary and tricuspid valves, the liability of the valves on the left side 
being greater towards the end of foetal life, as more and more work is imposed 
upon the left heart. In some cases a complete stenosis of the pulmonary 
and tricuspid orifices takes place, the heart becoming trilocular. Thus, in the 
case of an infant markedly cyanotic during life, but who lived for four 
months, it was found that the pulmonary orifice was completely closed, the 
tricuspid only admitted a crowquill, and the right ventricle was contracted and 
diminutive. There was an open foramen ovale, and the pulmonary circula- 
tion had been maintained by an open ductus arteriosus, the lungs being thus 
supplied by the aorta. In other cases where the stenosis of the pulmonary 
artery is only partial, the patient may live for years or even reach adult life ; 
there is usually an open foramen ovale, or ductus arteriosus, or defective 
interventricular septum ; cyanosis is mostly present, of a more or less high 
grade ; the child easily gets out of breath, is backward in talking and 

1 See case reported by Hutton in the Abstracts, Children's Hospital, Pendlebury, 1883, 
p. 45 ; and Keating and Edwards, Arch, of Pediatrics, p. 134, 1887. 



Congenital Heart Disease 



40 r 



getting on its feet, and is incapable of any great amount of exertion. The 
murmur present is usually loud, superficial, and rasping, being best heard 
over the pulmonary valves, over the second left costal cartilage near the 
sternum. There may be signs of dilatation of the right ventricle, such as 
epigastric pulsation. 

This is perhaps the commonest form of congenital heart disease found 
in children who have survived infancy and early childhood. Such children 
may live to grow up, but are apt to suffer from tuberculosis or to be carried 
off by bronchitis or pneumonia. Post-natal endocarditis is sometimes 
superadded. The diagnosis is not always easy between pulmonary stenosis 
and open foramen ovale without other lesion, especially as the bruit heard 
may result from the presence of both lesions. In pulmonary stenosis there 




Fig. 76.— Congenital Heart Disease, from a child aged 19 months. Stenosis of the pulmonary 
artery. «, aorta ; b, pulmonary artery ; c, patent ductus arteriosus. 



is more likely to be cyanosis and a dilated right ventricle, with the murmur 
confined to, and heard loudest in the pulmonary area. Cadet de Gassicourt 
has reported a case where a bruit was produced through enlarged glands 
pressing on the pulmonary artery. 

Stenosis of the Aorta or Mitral Valve. — In some cases there appears 
to be a congenital smallness of the aorta and arterial system, though it most 
commonly is the result of undergrowth, being secondary to some other cardiac 
lesion, by reason of which the arterial system is imperfectly supplied with 
blood. An endocarditis occurring late in foetal life sometimes affects the 
aortic valves, and an endocarditis may also occur after birth, and still further 
deform or pucker the valves. In such cases, if there is marked obstruction 
at the aortic valves, the ductus arteriosus may remain open, and some of the 

D D 



402 Diseases of the Circulatory System 

blood may pass, as it does during fceta! life, from the pulmonary artery into 
the aorta, without passing through the lungs ; the left ventricle becomes 
hypertrophied. When the stenosis is only moderate, life may be prolonged 
for many years. Stenosis of the mitral valves may also occur. 

Transposition of the Aorta and Pulmonary Artery. — This curious 
malformation is not uncommon ; the foramen ovale and ventricular septum 
remain open. Lite is rarely prolonged for more than a few months ; there 
is much cyanosis, but no bruit is present. A diagnosis during life is hardly 
possible. Of the many other malformations or arrests of development, such 
as a heart consisting of single auricle and ventricle, or a three-chambered 
heart, it is unnecessary to speak. 




Fig. 77.- Same heart as fig. 76. Right ventricle opened, a, aorta arising from both ventricles ; 
b, pulmonary artery, valves adherent, only admits a large probe ; c, incomplete interventricular 
septum ; d, tricuspid valves. 



Diseases of the Pericardium 

In a few cases a congenital absence of the pericardium or some defect 
in the pericardium has been recorded. In some cases a hernia or diver- 
ticulum has been present ; these congenital defects are of little practical 
interest. 



Pericarditis 

Etiology. — In children, as in adults, the most important association of 
pericarditis is with rheumatism, acute or subacute, as it arises more often 
during a rheumatic attack than under any other condition. An exception to 
this however occurs, for in children under three years of age rheumatism is 
an uncommon ailment, and pericarditis when present is most frequently the 
result of an extension of the inflammation from a pleuro-pneumonia or 
empyema or arises in association with such attacks. It is by no means 



Pericarditis 403 

uncommon to hear a pericardial friction sound during an attack of pneumonia 
in young children, or perhaps to discover/^/ mortem that a pericarditis has 
taken place in a case which was looked upon during life as one of simple 
broncho- or pleuro-pneumonia. In such cases, if they recover, a chronic 
pericardial effusion, sometimes purulent, may remain after the pulmonary 
lesion has been recovered from. 

Pericarditis occasionally occurs during an attack of scarlet fever, either 
associated with synovitis, or it may be in the absence of any joint com- 
plications. It occurs also during the course of post-scarlatinal nephritis, 
as a result of a uraemic condition, and under such circumstances must be 
looked upon as of extremely evil augury. It may occur during septicaemia, 
to whatever cause this may be attributed, or in periostitis and ostitis, and we 
have known it supervene in an attack of influenza. 

Pericarditis occurring in a child over three years of age is most frequently 
associated with the rheumatic state. Not that it only occurs during an attack 
of acute rheumatism, for it may supervene when there is no joint pain what- 
ever, or when the joint pain is slight ; but it occurs in a rheumatic individual, 
one who has already suffered from an attack, or who suffers from some of 
the associations of rheumatism, such as chorea, erythema nodosum, or endo- 
carditis. Pericarditis is apt to crop up in an unexpected and unexplained 
manner, and it should be carefully looked for whenever indefinite precordial 
or epigastric pain is complained of. It must be borne in mind that, like 
pleurisy, it occurs in an extremely mild form ; a pericardial rub may be heard 
unexpectedly in the absence of any definite symptoms in children who are 
going about and make no complaint of pain or dyspnoea. These attacks 
pass away, and presumably leave more or less of adhesions between the 
visceral and parietal layers of the pericardium. Does pericarditis recur ? 
No doubt it does, in spite of fibroid adhesions and damage to the serous 
layer by former attacks. 

Cases of pericarditis occurring during foetal life have been recorded by 
Billard, Bednar, and others. It also occurs in the septicaemia of the newly 
born, secondary to an inflammatory condition of the cord. 

Symptoms. — -The subjective symptoms are usually ill defined, especially 
in young children, and are of comparatively little importance as helps to 
diagnosis. The signs and symptoms mostly to be relied on are : (1) The 
presence of a pericardial friction sound. (2) An increased area of cardiac 
dulness proportionate to the effusion present. (3) The disappearance of the 
apex beat, or the position of the apex beat is raised and its area extended. 
(4) There is heart pain and perhaps tenderness on pressure over the cardiac 
region. (1) A pericardial friction sound can hardly be overlooked if carefully 
listened for, and is not likely to be mistaken for valvular murmurs, except, 
perhaps, in the case of infants the subject of congenital heart disease, the 
murmur in such cases being often harsh and superficial. It must not be for- 
gotten that the presence of a friction sound is not incompatible with a large 
amount of effusion into the pericardial sac. It mostly, however, disappears 
as effusion takes place, and reappears as the liquid becomes absorbed. 
(2) As effusion takes place into the sac, the area of cardiac dulness is neces- 
sarily increased in proportion to the amount of fluid present. The peri- 
cardium of a healthy child (age 6-9 years) when fully distended contains, 



404 Diseases of tlie Circulatory System 

according to Sibson, about 6 oz.,' but much larger quantities than this are 
often present : the effect of the distension of the sac with fluid is to increase 
the cardiac dulness laterally, and in an upward direction, the lungs, especially 
the left, being pushed on one side, so that the dulness extends to the second 
left costal cartilage, or even as high as the clavicle, and over a corresponding 
portion of the sternum. In lesser effusions the fluid tends to accumulate in 
the lowest part, and so modifies the dulness in a lateral direction. (3) The 
cardiac impulse disappears and the sounds become faint if the effusion is 
large, as a layer of fluid is interposed between the heart and the chest walls. 
Instead of the apex beat disappearing, it may be diffused and raised so as to 
be palpable or visible in the third and fourth spaces, as pointed out by 
Sibson. (4) Pericarditis may take place without any complaint of pain on 
the part of the patient, and hence may be easily overlooked in a mild case. 
In severe cases the pain is referred to the cardiac region, and pressure with 
the fingers or stethoscope causes pain. 

The discovery of a friction sound is usually the first thing to call at- 
tention to the attack. There may be only a slight rub or a loud grating 
sound heard all over the chest. At this stage, where there is no fluid present, 
presuming there is no valvular disease or dilatation, there is no, or but little, 
dyspnoea, probably more or less pain in the chest, quickened pulse and 
moderate fever. The amount of fever present is variable, seldom very high — 
101 F. to 103 F. in a severe case ; the temperature usually falls by lysis 
towards the end of the week. The rub may disappear in a few days in con- 
sequence of adhesions being formed. On the other hand, the friction sounds 
may entirely or in part disappear in consequence of effusion taking place ; 
as the effusion increases dyspnoea becomes more marked : at first it is 
slight, but if the effusion becomes large the dyspnoea increases, coming on 
in paroxysms accompanied by cyanosis, and there is perhaps a small, 
irregular pulse. It must not be forgotten that a considerable effusion may be 
present, and yet a loud friction sound be heard, caused by a small portion 
of the roughened layers of pericardium coming in contact. Death may be 
sudden at this stage, especially in those cases where pericarditis supervenes 
on old heart mischief, and the cardiac walls have become degenerated. In 
other cases the fluid is gradually absorbed, the friction is again heard more 
or less intensely, and finally disappears as adhesion takes place. 

No inflammatory affection differs more in intensity than rheumatic peri- 
carditis. There is little doubt that slight attacks occur which are over- 
looked, for a pericardial friction sound is heard at times when least expected, 
and disappears again without producing any symptoms of importance, or 
without the child having been ill, or it may be discovered during an inter- 
current attack of scarlet fever or pneumonia. On the other hand, acute 
pericarditis, or ' acute carditis,' as Dr. Sturges has called it, is a severe and 
dangerous affection, especially when it supervenes in patients whose mitral 
valves have been damaged by attacks of endocarditis, and dilatation of the 
heart cavities has occurred. The damaged heart has, when surrounded by 
lymph and fluid, to struggle with an increased load, and no wonder the 
prominent feature of the attack is cardiac failure. In these severe cases 

1 In enlarged hearts at this age, the pericardium may contain two or three times this 
amount. 



P erica rditis 405 

there is a quickened and perhaps irregular and intermittent pulse, orthopncea, 
vomiting, with an anxious and worn expression of face. In the worst cases, 
when the effusion of fluid is great, the patient has an ashen or cyanotic look, 
he sits up in bed leaning forward, and bringing all the extra muscles of 
respiration into play in the struggle for breath. Oedema of the extremities, 
ascites, and pleural effusion may be present. 

In the slighter cases of pericarditis, loose adhesions or attachments may 
take place between the two layers of the pericardium. The result of a single 
attack may be unimportant, but if there are repeated attacks, and they are 
severe, tough and thick adhesions are formed. The heart is thus surrounded 
by a thick fibrous coat, perhaps one-eighth to a quarter of an inch in thick- 
ness, which clogs and impedes the systole of the ventricles. Gradual 
dilatation of all the cavities takes place, with thinning of their walls. This 
condition of things is naturally made worse by an endocarditis, which 
thickens and deforms the mitral and perhaps the tricuspid valves. Thus, as 
an illustration of these results, we may refer to the following case. A girl of 
twelve years, who had suffered from chronic heart disease for some years ; at 
the post mortem the heart with the attached pericardium and containing clot 
weighed twenty-two ounces, the pericardium was thick and adherent and 
leathery, all the cavities were dilated, the mitral valve had suffered from old 
and recent endocarditis, the tricuspid orifice and the pulmonary artery were 
abnormally wide, the aorta was small, just admitting the little finger, and 
indeed the aorta and its branches were no larger than those of a child of 
three years. No doubt in this case the aorta had failed to develop normally 
on account of the small amount of blood which passed through it. In these 
cases it is possible that the dilatation is really an acute and rapid process 
occurring during attacks of rheumatism, and not entirely the result of an 
adherent and thickened pericardium. 

There can be little doubt, as both Dr. O Sturges and more recently Dr. 
D. B. Lees have pointed out, that what often passes as pericarditis is in reality 
acute carditis or myocarditis — that is, the changes are not confined to the 
pericardium, but the muscles of the heart walls may suffer severely from the 
effects of the rheumatic toxines, and, as a consequence, the muscular walls 
are weakened and the cardiac cavities become dilated. This dilatation is 
an active process in acute cases, and is not dependent upon mitral regurgitation, 
the result of endocarditis. Dr. Lees also points out that acute dilatation may 
take place during a rheumatic attack without the assistance of pericarditis, 
though it is much more pronounced if pericarditis is present. A first attack 
of rheumatism may lead to an acute dilatation of the heart if the attack is a 
sharp one, and if it does not prove fatal it may leave a much-dilated condition 
and perhaps adherent pericardium. 

An effusion into the pericardium, like an effusion into the pleural cavity, 
may be chronic. It sometimes happens, as we have already pointed out, 
especially in young children, that a pericardial and pleural effusion takes 
place, the latter becomes absorbed, and adhesions form while the peri- 
cardium remains distended with fluid. If the child is seen for the first time 
when this has occurred, an error in diagnosis is very easy, as the dulness 
caused by a distended pericardium shades away into the impaired resonance 
given by a compressed and adherent left lung. We have several times seen 



406 Diseases of the Circulatory System 

in young children fluid aspirated from the pericardium by a needle passed 
into the axilla, when it was believed the fluid was being drawn from the left 
pleural cavity. In these cases, it was found at the post-mortem examination 
the needle had passed through the compressed left lung and entered the 
distended pericardium. 

A chronic pericardial effusion is sometimes present in tubercular sub- 
jects, after the manner of a peritoneal effusion : this may be of long 
standing, and the diagnosis may be difficult, as the effusion may be 
associated with a mediastinitis and may suggest the presence of mediastinal 
tumour. This was so in the following case : 

Chronic Pericarditis and Peritonitis, Contracted Mitral, General Miliary Tuber- 
culosis. — John Hy. P., aged 7 years. Mother states he has always been a healthy boy till 
four months ago, when he had bronchitis ; has been wasting ever since ; his belly has 
been swelling since. Admitted August 27, 1885. Is an anaemic, flabby boy, with dis- 
tended abdomen, evidently containing much peritoneal fluid ; right side of chest is 
normal ; the left is quite dull in front, reaching to the clavicle above, and shading away 
in the stomach resonance and into axilla, which is also resonant ; the whole cardiac area 
is included in the dull area, the dulness extends to the right just beyond the right sternal 
line ; posteriorly the percussion note is normal ; over the dull area there is bronchial 
breathing both with ex- and inspiration ; there are no moist sounds ; the cardiac impulse 
is not visible or palpable ; cardiac sounds normal ; the veins on the chest are enlarged and 
tortuous ; there is marked ascites ; the liver is enlarged ; the spleen not felt ; urine not 
albuminous. September 24. — Boy continues much in same state ; less ascites ; the 
temperature continues normal or subnormal ; he does not appear ill or in any way 
uncomfortable ; the glands in the neck under jaw are enlarging. November 11. — Went 
home for a while. Readmitted December 10, 1886. Has been fairly well at home, except 
he has bad cough and his belly has swollen more ; physical signs in chest much the 
same ; there is, however, more dyspnoea ; the face has a bluish tinge, and the superficial 
veins on chest more distended ; exploration of chest in dull area with a hypodermic 
syringe ; some straw-coloured coagulable fluid like serum was withdrawn. January 22. — 
Has been getting worse for some weeks past ; temperature has since December 13 been 
99°-ioi -io3° ; the physical signs have not materially altered, except there is some 
impaired resonance now at base of left lung behind. January 24. — Has been vomiting; 
pulse 96 ; irregular and intermittent ; temperature 98°-io2°. January 25. — Continues to 
vomit ; the ascites has much diminished. Died January 27. — Post-mortem. — Some 
emaciation ; some bulging over cardiac area ; on opening chest it is seen the pericardium 
is distended, pushing the left lung away to the left out of sight, the edge of the right lung 
partly overlapping pericardium ; there is a complete matting together of the pericardium 
and mediastinal glands with excess of fibre-tissue; the mediastinal glands are enlarged, 
containing miliary tubercle ; some are shrunken and pigmented ; the right lung is normal ; 
the left is compressed, surrounded by old adhesions and recent miliary tubercle ; on 
section it is condensed ; recent pulmonary apoplexy ; the pericardium is adherent to the 
parts around ; on cutting into it its walls are nearly \ inch thick, it contains 2 or 3 oz. of 
serum and much loose granular lymph ; heart somewhat small, lymph on the surface ; 
mitral valve only admits forefinger ; tricuspid, zh fingers ; edges of mitral valve hard and 
sclerotic ; left auricle wall thickened ; left ventricle cavity small ; right ventricle dilated ; 
a few ounces of fluid in peritoneum ; omentum indurated, covered with recent miliary 
tubercles ; large and small intestines covered with miliary tubercles ; no ulcers internally ; 
liver adherent to the diaphragm and covered with miliary tubercles ; section fatty ; kidneys, 
a few cheesy tubercles ; spleen normal ; brain, lymph in Sylvian fissures, around cere- 
bellum, and in interpeduncular space ; fluid in the ventricles ; tubercle on the vessels. 

Chronic pericardial effusions are apt to become purulent, and in rare cases 
the pus may find its way to the surface after the fashion of an empyema ; this 
happened in one of our own cases, a child of eighteen months, the abscess 



Pericarditis — Endocarditis 407 

pointing near the tip of the sternum ; after the abscess was opened the child 
died of exhaustion, and the diagnosis was verified post mortem. In such 
cases there is much difficulty in deciding as to the origin of the pus : as to 
whether the abscess is a collection of pus finding its way out from the 
mediastinum or from the pericardium. It may also be a local empyema or 
periosteal abscess. 

Complications. — In rheumatic pericarditis, endocarditis is exceedingly 
likely to occur during the attack. Pleurisy or pleuro-pneumonia may be 
present ; more rarely peritonitis and meningitis. 

Diagnosis. — A pericardial friction sound is not likely to be confounded 
with anything else, unless, perhaps, it is an exo-cardiac sound, such as is pro- 
duced by the external surface of the pericardium rubbing against a roughened 
pleura ; but this latter is heard only, or at any rate more loudly, during 
inspiration. The difficulty most likely to occur is, in a case in which there 
is admittedly old cardiac mischief, to distinguish between dulness due to the 
presence of fluid and that due to a dilated heart. To anyone who has care- 
fully watched a case from the commencement of the heart disease this diffi- 
culty may be small ; but in cases which are suffering from great dyspnoea and 
distress, in which pericarditis and dilated ventricles exist together, it is often 
difficult to decide when the child is seen for the first time what amount of fluid 
is present and what share it takes in the production of the cardiac distress. It 
must be borne in mind that if the amount of fluid is excessive, there is dul- 
ness as high as the left second intercostal space. In a large dilated heart 
there will be bulging of the chest walls, and an extended area of pulsation 
in part outside the left nipple line. It has been pointed out by several 
writers (Rotch, Dickenson) that dulness extending to the right fifth inter- 
space is probably due to fluid ; this however is not by any means always the 
case, but may be due to a dilated right heart. 



Endocarditis 

Inflammation of the membrane lining the heart, more especially that 
part which covers the valves, occurs at all periods of life. It may attack the 
foetus and then usually affects the pulmonary or tricuspid valves ; but if it 
occur in the last few weeks of foetal life it may affect the mitral and aortic 
valves. It may also occur during the two or three years succeeding birth ; 
it is, however, less common at this period than later, though it is probably 
often overlooked. It is common during the later periods of childhood and 
youth. Like pericarditis, its usual association is with the rheumatic state, 
not that there is necessarily marked tenderness of the joints and high fever, 
but the patient exhibits some of the symptoms or associations of rheumatism, 
such as chorea, or erythema nodosum, or he has suffered from undoubted 
joint troubles in the past. During an attack of rheumatism, children are 
especially prone to suffer from endocarditis, and the proportion of those who 
do suffer is greater than in the case of adults, being in the case of children 
perhaps 75-80 per cent. ; in adults the proportion must be far less than this. 
Endocarditis also occurs in scarlatinal synovitis ; the heart does not, however, 
so often suffer here as in simple rheumatism. In nephritis, in pyaemia, and 
during attacks of any of the zymotic fevers, especially diphtheria, endocarditis 



408 



Diseases of the Circulatory System 



may occur. In all febrile conditions a difficulty may arise in the diagnosis, 
in distinguishing murmurs due to organic disease from ha-mic murmurs. 
During fever the circulation is disturbed and the cardiac beats increase in 
number, the first cardiac sound being wanting in sharpness, or there may 
be a ' murmurish ' sound heard ; if this disappears during convalescence we 
are hardly justified in saying that an endocarditis has existed. That endo- 
carditis does occur at times during an attack of scarlet fever or during con- 
valescence is certain ; it is, however, rare to find the valves affected in a fatal 
case of scarlet fever. 

Malignant or ulcerative endocarditis arises in some instances in connec- 
tion with the rheumatic state, being engrafted on to an ordinary rheumatic en-, 
docarditis ; it occurs in connection with acute nephritis, suppurative periostitis 
and osteomyelitis. It appears sometimes to follow scarlet fever. Recent 
observations have shown the presence of septic micro-organisms, such 
as streptococci, staphylococci, and FraenkeFs pneumonia diplococci on 
the valves in malignant endocarditis, and it would appear as if a simple 




illiilililiilliiiliiliilllilillliiii 
illllilllllllliillllli llililililli 




■111 

SSSB 

iiiiiii 



Fig. 78. — Temperature Chart of a case of Endocarditis supervening on the sixth day of a 
mild Scarlet Fever ; there were no joint lesions, the bruit persisted, and dilatation of the 
left ventricle followed. 

endocarditis afforded a suitable soil for the development of these pyogenic 
micro-organisms. We have several times got cultivations of streptococci 
on gelatine from blood drawn from the finger in cases of malignant endo- 
carditis. 

The symptoms of simple endocarditis, such as occurs during rheumatism, 
are not distinctive. There is often precordial pain, perhaps some dyspnoea, 
usually some fever of an intermittent type (see fig. 78), though this, in some 
instances, may be due to the rheumatism present ; indeed, the only symptom 
upon which any reliance can be placed is the presence of a bruit : it is certain, 
however, that endocarditis may exist without a bruit being present. It 
sometimes happens that during an attack of rheumatism or chorea the most 
careful examination may fail to detect a bruit, and yet, if the patient is 
examined a month or two after, a bruit is detected, which comes rather as a 
surprise. In the vast majority of cases it is the mitral orifice which is 
affected, a murmur being heard which replaces or accompanies the first 
sound at the apex. Dr. O. Sturges points out that in some cases a faint 
murmur heard at the top of the ensiform cartilage, indicating regurgitation 



Endocarditis 409 

at the tricuspid orifice, precedes the mitral bruit, the tricuspid regurgitation 
being due to back pressure through the lungs. The constitutional disturbance 
is but slight, or at least it is impossible to separate the symptoms produced 
by the endocarditis from those produced by the rheumatism. When a re- 
current attack of endocarditis takes place in a case of old heart disease, where 
there is mitral regurgitation and a bruit present, it is rarely possible to make 
a definite diagnosis. 

When the endocarditis is of the malignant or ' ulcerative ' variety, the 
constitutional symptoms are usually much more marked, and are those of 
septicaemia engrafted on to heart disease. It may supervene in a subject 
already suffering from rheumatic heart disease, post-scarlatinal nephritis, or 
periostitis. In some cases the symptoms are very like those of acute tuber- 
culosis, and in one case which came under our notice a death certificate to 
that effect was given, a subsequent post-mortem showing the real nature ot 
the disease to be acute endocarditis. In such cases the bruit may be of a 
musical character and accompanied by a thrill ; the aortic valves may also 
be affected and be the seat of a bruit. There is usually precordial pain, often 
pain in the left shoulder ; a hectic temperature rising to 103 or 104 in the 
evening and falling in the morning, an enlargement and often tenderness of 
the spleen. The urine is usually albuminous, often highly so. There may 
be joint pain and some of the phenomena of embolism. In one of our own 
cases there was aneurism due to embolism of the middle cerebral artery ; in 
another embolism of the lenticular striate artery. 

In any case of undoubted heart disease with intermittent pyrexia, malig- 
nant endocarditis should be suspected, especially if there is enlargement of 
the spleen and albuminuria. The aortic, tricuspid, and pulmonary valves 
are often affected in malignant endocarditis ; the fact that an aortic bruit is 
heard in a case of acute cardiac disease may help us to decide in favour of 
malignant endocarditis. The following case of malignant endocarditis may 
be taken as an example : 

Malignant Endocarditis— Embolism of Brain and Spleen. — Sarah E. C. , aged n years. 
Mother has had rheumatic fever. Four children have died of wasting and convulsions. 
Last Christmas child had chorea for three months and also rheumatism. A month ago 
child complained of pains in limbs. She has a cough and is short of breath, but has 
been going to school up to a fortnight ago. Admitted August 20, 1891. Heart. — Apex 
beat in sixth space, outside nipple line, no thrill, musical systolic murmur at apex, does 
not replace the first sound ; second sound accentuated, no bruit. Lungs, normal. Urine, 
trace of albumen. August 27. — Child has improved. There is a presystolic as well as a 
systolic bruit ; slight presystolic thrill. Temperature goes to ioo° at night. Sep- 
tember 9. — No presystolic murmur now; rough systolic at the apex well conducted into 
axilla. Temperature 99 to 103 . At 7 p.m. last night child complained of pain in right 
arm and leg. An examination this morning shows complete hemiplegia, the right arm 
and leg are paralysed ; there is also facial paralysis of the same side ; knee jerk diminished ; 
plantar reflex present ; slight dropsy of right eyelid ; hemi-anoesthesia of the same side. 
Child not unconscious ; tongue protruded to right ; speech indistinct and thick ; no certain 
loss of memory for words ; she will give the names of common objects ; no optic neuritis ; 
spleen much enlarged, no albumen. November 24. — Patient has been getting weaker 
since last note and more anaemic, her face becoming quite pallid. Temperature has varied 
from 99 to 103 ; the paralysis is much the same, except that contracture has become 
more marked during the last few weeks, and the knee jerk more pronounced. Early on 
the morning of November 24 she became unconscious, the breathing: stertorous ; she 
lingered a few hours in this state and then sank. Post-mortem. — Lungs. — Both lungs 



4io Diseases of the Circulatory System 

studded with pale infarcts, hypostatic pneumonia at bases of both lungs. Heart. — Much 
enlarged, extending from nipple to nipple; some two ounces of fluid in the pericardium ; 
no pericarditis. Left ventricle dilated and containing much dark clot ; mitral valve 
covered with large warty granulations which can be readily detached ; posterior surface 
of left auricle is the seat of numerous granulations ; there is also a small patch on the 
surface of the ventricle, where there has been friction or where a flap of the mitral valve 
has impinged. All other valves are normal. Liver. — Congested, nutmeg, and much 
enlarged. Kid?ieys. — Right kidney contains an infarct of some standing; left also. 
Spleen. — Very large, contains two large infarcts. Brain. — Brain appears firm and 
healthy. There is an embolus at the junction of middle and anterior cerebral arteries 
on the right side ; there has evidently been embolism of one of the branches of the middle 
cerebral of the left side in the Sylvian fissure, as it is white and apparently plugged. 
Making horizontal sections through the brain, the first section shows some surface soften- 
ing of the left ascending parietal convolution. Section made through the roof of the 
lateral ventricle shows softening of the convolutions of the island of Reil and caudate 
nucleus. Section through internal capsule shows a patch of softening involving the 
lenticular-striate artery, which is plugged with clot and impervious. The softened parts are 
of a rusty colour. The hemiplegia was no doubt due to an embolus in the left lenticular- 
striate artery, and the softening on the surface to embolism of branch of left middle 
cerebral (see fig. in). 

There are other cases of acute endocarditis, however, which end in recovery at any 
rate for a time. We have seen several cases where there has been pyrexia of an inter- 
mittent type for many months gradually improve, and finally the temperature has become 
normal, and they have been able to get about and appear quite well, but have doubtless 
had damaged mitral valves. 

Chronic Heart Disease 

The immediate result of endocarditis is to cause a swelling and roughness 
of the endocardium which prevents the complete closure of the valves and 
thus allows of regurgitation (see fig. 79) ; puckering and thickening of the 
valves takes place as time goes on, especially if there are recurrent attacks, 
and the valves become permanently damaged. In children it is the mitral 
which almost constantly suffers. In some chronic cases the valves become 
adherent at their edges, and thus stenosis is produced. Gradually other 
and compensatory changes take place ; if the regurgitation occurs at the 
mitral orifice, the left ventricle gradually dilates and becomes hypertrophied. 
At first the compensatory changes which take place are sufficient to prevent 
the patient from feeling any inconvenience, and both he and his friends may 
be ignorant of the existence of valvular disease ; but sooner or later dyspnoea 
on exertion and precordial pain are complained of, which direct attention to 
the heart. Such patients often suffer from bronchitis — a result of the con- 
stant congestion of the lungs which is present in mitral regurgitation. If a 
physical examination of the heart is made at this period, a bruit is detected, 
heard loudest at the apex, but well conducted into the axilla and to the 
angle of the scapula ; the click of the pulmonary valves is accentuated, while 
the aortic sounds are weak. The apex beat is diffused and situated outside 
the nipple line, the cardiac dulness is increased to the left and frequently also 
to the right, as the right ventricle is apt to be dilated on account of the con- 
gested state of the lungs. In some cases the heart becomes enormously 
enlarged, so that the area of cardiac dulness extends from nipple to nipple, 
and the apex beat occupies perhaps the fifth, sixth, and seventh spaces outside 
the nipple line, while the whole of the precordial region is bulged forward 



Chronic Heart Disease 



41 



by the hypertrophied heart. Often the left bronchus is pressed upon and the 
lower lobe of the lung becomes collapsed. During the last stages, which 
may be short or prolonged intermittently for many months or even years, 
the liver becomes congested and enlarged, there is albuminuria from con- 
gested kidneys, while the belly, scrotum, and legs become dropsical. 
Attacks of dyspnoea with pain resembling angina pectoris are not un- 
common towards the last. Such cases may be very chronic, and even 
repeated attacks accompanied by much orthopncea, cardiac distress, bron- 
chitis, and dropsy may be recovered from and the patient once more be 
patched up. In such cases, however, probably no fresh endocarditis occurs, 
and the attack is due more to the engorged state of the lungs and a 




Fig. 79. — Acute Endocarditis of Mitral Valves in 
(See Fatal Case of Chorea.) 



case of Chorea. 



temporarily overworked heart, the latter recovering by rest in bed, and the 
symptoms disappearing as the bronchitis passes off. Should, however, peri- 
carditis occur in a case of old-standing heart disease, the end is not far off, 
as the muscle becomes damaged and further work is imposed on an already 
burdened heart. 

In order to illustrate the lesions most commonly found in chronic heart 
disease in children, we have analysed the results of forty-one post-morte7iis 
made at the Children's Hospital, Manchester, during the last few years, on 
patients who have been under the care of our colleague Dr. Hutton or one 
of ourselves. The youngest was three years and eight months at the time 
of death, and the oldest fourteen years. With one exception all died from 



412 Diseases of the Circulatory System 

the results of chronic heart disease — that is, the heart disease was primary, 
those cases dying with pericarditis or endocarditis accompanying septicaemia 
or other fatal disease being excluded. They may be divided into the follow- 
ing groups : 

1. Malignant ' ulcerative ' endocarditis with embolisms 

in various organs. Pericarditis mostly absent . . 5 cases 

2. Acute pericarditis occurring in a heart already more or 

less dilated from the effects of mitral disease, and 
perhaps old pericarditis. Recent endocarditis mostly 
slight, coincident with the pericarditis . . . .20 cases 

3. Adherent pericardium. — Former attacks of pericarditis 

which had given rise to thick leathery adhesions around 
the heart, and in connection with old mitral disease 
had given rise to extensive dilatation and gradual heart 
failure. A small aorta usually present and dilated 
pulmonary artery ; mostly bronchitis and hypostatic 
congestion of the lungs ....... 10 cases 

4. Chronic valvular disease without pericarditis. — 

Mitral incompetency, dilatation of both ventricles, 
bronchitis and hypostatic congestion of the lungs. . 6 cases 

In the above forty-one cases the pericardium had been affected thirty 
times ; in the remaining eleven no inflammatory lesion of the pericardium 
had taken place, but clear fluid without lymph was present in several of 
these. In several cases of acute pericarditis the amount of fluid was ex- 
cessive, amounting in one case in a girl of nine years to 20 oz., the heart 
with the distended pericardium measuring 6| in. from right to left ; in 
another the pericardium contained 14 oz. In other cases the cavity of the 
pericardium was obliterated by old adhesions forming a thick layer one-eighth 
to one-quarter inch thick, which had evidently played an important part in 
bringing about the fatal result. 

The mitral orifice was affected in every case ; in the malignant variety 
of endocarditis there were the usual luxuriant vegetations present, mostly 
extending along the posterior wall of the left auricle where the regurgitant 
stream of blood had impinged. In the slighter forms of endocarditis the 
lines of contact of the valves were simply roughened, having lost their shiny 
surface. In other cases there was evidence of old endocarditis, the edges 
of the flaps were thickened, the chordae tendineae were thick and short, and 
in one case several chordae had ruptured. As a result of this and also of 
the dilatation of the ventricles, the mitral orifice was incompetent, the valves 
not meeting during systole, or if coming in contact the roughened surface 
allowing blood to regurgitate into the auricle. In only two cases was there 
any stenosis of the mitral orifice, mostly the orifice admitted two fingers side 
by side, or it was wider still. In one of the cases of stenosis the mitral 
orifice only admitted one finger, the boy had not had rheumatism ; he died 
of tubercular pericarditis and peritonitis (see case, p. 406). In the other case 
the patient was a boy of thirteen, who had been in the hospital five times 
with chorea, and finally with chronic lung trouble. At the post mortem there 
were caseation and small cavities in the lungs, no definite tubercle anywhere, 



Chronic Heart Disease 413 

a puckered and funnel-shaped mitral orifice, and recent and old endocarditis 
of the tricuspid valves. 

The aortic valves were affected in twenty, that is, in about half the 
cases, but the lesions were of a far less advanced or serious nature than in 
the case of the mitral. In most of the cases the valves were competent, 
and in no case had regurgitation apparently occurred to any great extent. 
Six times the note was made, ' The aorta only admits the little finger ; ' this 
was due not to the effects of valvular disease but to undergrowth in the aorta, 
which has already been referred to. 

The tricuspid valves were affected thirteen times, or in about one-third of 
the cases, either by recent or old endocarditis. Probably the tricuspid valves 
were incompetent in the majority of cases in consequence of the dilatation 
of the right ventricle. The note often occurs that the tricuspid orifice was 
abnormally wide, and on one occasion it admitted four fingers side by side. 

The pulmonary valves in two cases had slight vegetations on them 
along the lines of contact. In most cases the pulmonary artery was dilated 
from the effects of back pressure. 

The murmurs heard during auscultation in the case of children are in 
some ways more puzzling than those heard in adults. This is due in part 
to the more rapid action of the heart, and this is especially the case in trying 
to time a murmur present in the case of congenital heart disease in an infant. 
In chronic heart disease in children the hearts are larger and occupy more 
space in the chest as compared with adults. Exocardial sounds are com- 
moner in children, and may be mistaken for murmurs. 

In acute febrile diseases like scarlet fever or influenza, a murmurish first 
sound may often be heard, and inasmuch as endocarditis does at times 
occur in these diseases, we may at times be in doubt as to whether the 
abnormal sound is due to endocarditis or not. In these cases even an 
experienced ear may be deceived and an endocarditis is suspected, when 
the sequel proves this to have been a mistake. The bruit may disappear as 
the pulse and temperature fall. Certainly, murmurish first sounds are heard 
during scarlet fever, which disappear during convalescence ; but, on the 
other hand, an endocarditis occurring during scarlet fever is apt to be over- 
looked. In acute rheumatism or chorea a slight endocarditis may be over- 
looked, inasmuch as it may not give rise to a murmur, the tiny swellings 
along the line of contact of the valves being too minute to allow of re- 
gurgitation, and it is only perhaps after some weeks, it may be during con- 
valescence, that the murmur is heard. 

Regurgitation through a damaged mitral valve gives rise to a murmur 
accompanying or replacing the first sound at the apex. Post-mortem 
evidence shows that if heart disease exists, there is regurgitation through 
the mitral orifice or damage to the mitral valve in practically all the cases, 
though other valves, as also the pericardium, may share in the damage. In 
the vast majority of cases there is regurgitation and no stenosis. In a con- 
siderable proportion of cases of chronic heart disease in children, especially 
where there is a dilatation of the cavities, there is a double or treble 
murmur at the apex, there being either a presystolic or a diastolic in 
addition to the mitral systolic. The presystolic is generally heard as a 
' churning ' or ' rumbling ' sound preceding the systolic bruit and running 



414 Diseases of the Circulatory System 

up to it. Is the presystolic under these circumstances diagnostic of a 
contracted mitral ? The result of our post-mortons lend no support to this 
view. In the two cases in which a contracted mitral was found post mortem 
there was no bruit at all heard during life in one, and a systolic bruit in the 
other. In the cases in which a presystolic and systolic were heard, there 
was no stenosis found post mortem, but in one case ruptured chordae, and in 
others thickened and puckered valves. No bruit is more perplexing than 
the so-called diastolic mitral. This apex diastolic is common enough in 
the later stages of chronic heart disease when there is much dilatation. In 
some cases there is a banging or intensified second sound at the apex, 
produced presumably at the pulmonary orifice, and perhaps the diastolic 
bruit may be what Dr. G. Steell has called 'the murmur of high pressure in 
the pulmonary artery,' which is well conducted to the apex. It can hardly 
be produced at the aortic orifice, as in some cases where it has been heard 
the aortic valves were normal and could not have allowed of regurgitation. 
We have noted this murmur in cases in which the pericardium was adherent 
and incases in which it was normal. On several occasions we have noted 
the presence of a diastolic bruit, and on a later occasion have described it as 
being presystolic, and this has been confirmed by others. 

Murmurs produced at the tricuspid orifice are best heard at the tip of 
the sternum, probably they are often masked by the presence of a loud 
mitral murmur. A double bruit at the base indicating stenosis and re- 
gurgitation at the aortic orifice is not common in children, though a systolic 
bruit is common enough. Often the mitral systolic is so well conducted to 
the base that a doubt may be raised as to whether there is aortic stenosis 
or not. In some cases in which a double bruit has been best heard over 
the pulmonary area, we have found post-mortem disease of the aortic valves, 
while the pulmonary have been healthy. 

Dilatation of the cavities of the heart takes place in children apart from 
valvular disease, under two circumstances — an excess of blood pressure, as in 
acute nephritis, the force acting from within and bulging the heart walls as it 
were ; a chronic pericarditis, with adherent pericardium interfering with 
the systole, and so tending to dilatation, or a carditis with or without pericar- 
ditis damaging the cardiac walls. Acute dilatation of all the cavities rapidly 
takes place in some cases of acute nephritis following scarlet fever ; the 
apex beat becomes diffused, and is seen outside the nipple line ; in a few 
cases there is a bruit, due to the imperfect closure of the mitral valves, and 
symptoms of cardiac failure, and perhaps sudden death may take place. 
Dilatation of the left ventricle may occur in anaemia. Dilatation due to 
chronic pericarditis is a cause of chronic rather than acute heart disease ; a 
pure case of this is rare, as endocarditis mostly occurs also ; but sometimes 
cases may be found in which the heart is enlarged and the cavities dilated, 
with a thick pericardial attachment outside ; the valves are normal or perhaps 
more or less thickened, and have evidently been incompetent during life. 
In these cases, as already pointed out, the dilatation has probably taken 
place during one or more rheumatic attacks. We have noticed signs of 
dilated heart with a muffled first sound in growing delicate boys towards 
puberty, especially if they are given to violent exercises. 



Chronic Heart Disease 415 

Acute Myocarditis. — Acute myocarditis, apart from rheumatic peri- 
carditis, is not a common affection at any time of life, and much difficulty 
exists in stating what it consists in, as any general acute process affecting 
the heart must quickly bring a fatal issue. Changes in the cardiac muscles 
of a coarse description do occasionally occur. In rare cases children have 
been attacked with an acute illness with fever and delirium, and at the 
post-mortem an unsuspected abscess has been found in the muscle of the 
heart ; such cases are probably septicemic, as also are those where minute 
abscesses are found. Acute myocarditis appears also to occur in diphtheria ; 
there is a general dilatation of the heart, more or less local pain, and dys- 
pnoea followed by a fatal issue, changes being found in the muscular fibre ot 
the heart, the muscular fibres being distended with fine granules of fat 
obscuring the striae. It is well known, however, that sudden death may 
occur in diphtheria from paresis of the respiratory muscles, as well as from 
disturbed innervation of the heart, so caution is required in coming to a con- 
clusion that a myocarditis exists. Steffen has described a form of local myo- 
carditis occurring in the course of typhoid, accompanied by symptoms of 
cardiac failure during life. Such cases must be rare. Myocarditis or a 
degeneration of the cardiac muscle may accompany both pericarditis and 
endocarditis. Steffen has also recorded cases of myocarditis with dilatation 
in some cases of purpura. 

Prognosis. — Acute pericarditis or carditis occurring in association with 
rheumatism is a dangerous affection, especially in young children. The 
younger the child, the worse is the prognosis. A rheumatic pericarditis 
occurring" in a child 4 or 5 years of age is exceedingly likely to end fatally or 
leave behind a much dilated and damaged heart. A sudden cardiac syncope 
may at any time take place. In less acute cases of pericarditis or peri- 
endocarditis, especially in older children, the immediate danger to life is not 
great, but the outlook in the long run is serious. Pericarditis occurring in 
a heart which is hypertrophied from old-standing valvular disease is an ex- 
ceedingly dangerous and fatal affection, and generally marks the beginning 
of the end. Death maybe sudden at the last. In endocarditis occurring in 
the course of rheumatism there is, of course, great danger that permanent 
damage may be inflicted on the valves and the patient be handicapped for 
life. On the other hand, there is abundant evidence to show that bruits 
due to endocarditis, occurring either in connection with chorea or rheuma- 
tism, may disappear, and there is no reason why the endocardium may not 
return to its normal condition without crippling the valves ; there is, 
however, the constant fear of a fresh attack at the old spot. The prognosis 
in malignant endocarditis is eminently unfavourable, though cases which 
apparently belong to this category occasionally recover. In chronic heart 
disease the amount of hypertrophy and dilatation present may be taken as 
an index of the damage the heart has suffered. The prognosis in dilated 
hearts secondary to nephritis is favourable if the nephritis subsides and no 
valvular disease remains. 

Treatment. — The treatment of pericarditis and that of endocarditis have 
so much in common that they may be taken together. It is needless to in- 
sist that the child should be put to bed and religiously kept quiet, all exertion 
and excitement being zealously guarded against. Too much stress cannot be 



416 Diseases of the Circulatory System 

laid upon the importance of this, and of maintaining rest in bed long after the 
acute symptoms have passed away. To keep the heart as quiet as possible, 
and to impose the lightest work on it, during and after the attack, are points 
of the highest moment. The diet given must be suited to the rheumatic state ; 
if peri-endocarditis is associated with it, milk and fluids will form the prin- 
cipal part. Of the local treatment during the acute stage, applications which 
soothe are better than counter-irritants. Ext. of belladonna moistened with 
glycerine may be spread on lint or flannel, and applied to the precordial 
region, and covered with a layer of cotton wool, or spongio-piline wrung out 
of hot water and sprinkled with laudanum maybe applied. If there is much 
pain, a light mustard poultice (one in four or six) kept on for some hours so 
as to redden the skin will usually relieve. Lin. aconiti and lin. iodi, equal 
parts, may be painted over the precordial regions. Local blood-letting by 
applying one or two leeches over the sternum is often useful in appropriate 
cases. Dr. D. B. Lees has highly extolled the effects of an ice bag applied 
to the pericardial region. We have seen cases where this method has been 
useful, but some patients rebel against it. Of medicines, salicylate of soda, 
with liq. ammon. acet. if the inflammatory lesion is dependent on the rheu- 
matic state, may be prescribed, tinct. digitalis being substituted and given 
in 3 to 5 minim doses every four hours if there is much dyspnoea or 
sign of cardiac failure. Small doses of opium are usually required, and 
are often of the greatest use in relieving pain and quieting the heart's 
action. Half to two grains of Dover's powder may be given at night, 
and repeated once or twice in the twenty-four hours, according to 
circumstances. (See also F. 75, 76, 77, 78, 81, and 82.) ( K Appe?idix.) 

In pericardial effusion, if extensive, tapping of the pericardium may have 
to be resorted to, to relieve the pressure on the heart. Before this is done 
as accurate a diagnosis as possible must be made, to ascertain how much 
the symptoms present, dyspnoea, orthopncea, and cyanosis, are due to pres- 
sure of fluid, and how much to a dilated or hypertrophied heart ; as many, 
perhaps most, of the cases of children with which we have to deal are in 
reality cases of pericarditis supervening on chronic heart disease. In the 
latter case, if there is much cardiac dilatation and comparatively little fluid, 
paracentesis cannot relieve to any extent, and the cardiac walls may be 
wounded, though if &fine exploring needle be used no great damage can be 
done. 1 The spot selected for paracentesis is usually the fourth or fifth inter- 
space, half way between the left nipple line and the left edge of the sternum, 
but care should be used to ascertain the position of the apex beat as nearly 
as possible. Having by the cautious use of an exploring syringe with a fine 
needle ascertained the presence of fluid, a trochar and cannula may be used 
to draw it off, care being taken to withdraw the trochar as soon as the 

1 On one occasion we tapped the pericardium with an exploring syringe armed with a 
large sharp-pointed hollow needle, and withdrew some two ounces of serum ; this was 
followed by pure blood. After the needle was withdrawn the child became rapidly worse, 
and died in a few minutes. The post-mortem showed the pericardium full of blood, and a 
puncture wound through the right ventricular wall close to the interventricular septum. 
The wall was very thin at this spot and almost fibroid. Had a trochar and cannula been 
used, the trochar being withdrawn on entering the pericardium, this accident could not 
have happened. The needle had entered the pericardial sac in the first instance, and then 
entered the right ventricle. 



Chronic Heart Disease 417 

cannula is well inside the cavity of the sac. As a matter of fact paracentesis 
pericardii is rarely of much use, though it may postpone the fatal result a 
few hours, and bring temporary relief. 

In chronic pericardial effusion the inunction of blue ointment or counter- 
irritation by flying blisters may be tried. In chronic purulent effusion, 
aspiration should be first tried ; if this fail to prevent reaccumulation, 
incision and drainage by an india-rubber tube should be resorted to ; this is 
occasionally successful, as in the case recorded by Dr. S. West. Symptoms 
of cardiac failure should be treated by digitalis, ammonia, ether, or alcohol. 
Ether may be injected subcutaneously or a few drops may be inhaled. The 
treatment of malignant or ulcerative endocarditis is unsatisfactory, and no 
drugs appear to influence its course. The most likely to be useful are 
quinine, digitalis, and the sulpho-carbolates. The treatment of congenital 
or chronic heart disease must be directed to saving the heart all unnecessary- 
work and to strengthening it as much as possible. Children with chronic 
heart disease need to be guarded most carefully against the effects of cold, 
as bronchitis is easily contracted in such, and a little bronchitis adds 
materially to the work of the heart, which is, perhaps, at best labouring 
under great mechanical disadvantages. The parents and friends of such 
children must be cautioned against allowing the child to over-tire itself; it 
is no uncommon thing for such a child to go for a while to the sea-side or 
convalescent home and come back worse, for the simple reason that it has 
been on its legs all day, enjoying the novelty of its newly found pleasures ; 
whereas a moderate amount only of exercise, insufficient to over-work the 
heart, would have secured an improvement. All active exercise should be 
forbidden, rough games, riding ' cycles,' and gymnastics. The medicines 
of most use to control and regulate the cardiac contractions are digitalis, 
belladonna, iron, and strychnine. Digitalis is of the greatest value, but must 
not be too continuously given ; any intermittency in the beat should be the 
signal for its omission. When dropsy sets in, digitalis with diuretics like 
iodide o potassium, acetate of potash, and squills will be required. (F. 79 
and 80.) In excessive dropsy Southey's cannulas may be used with advantage. 

Xftediastino-pericarditis, Pleuro. pericarditis 

An inflammation of the serous membrane which is reflected over the 
anterior edges of the lungs and surrounds the pericardium sometimes takes 
place, mostly in association with a more general pleurisy or with pericarditis. 
At times the pleurisy appears to be local, being confined to the serous mem- 
brane covering the pericardium and lung adjoining it. The symptoms of 
such an inflammation are necessarily indefinite, almost the only definite sign 
being a pleuro-pericardial friction sound — -that is, a rubbing sound which is 
synchronous with the cardiac beats, and which is more intense during inspira- 
tion as the lung expands and its edge passes in front of the heart. The rub 
may disappear entirely during expiration. The deeper the inspiration the 
more intense the friction sound becomes. As a result the edge of the lung 
becomes adherent to the pericardium, the space between the two becoming 
obliterated. In some cases a subacute or chronic inflammatory process goes 
on in the mediastinum, involving the serous membranes, connective tissue, 

E E 



41 8 Diseases of the Circulatory System 

and perhaps the mediastinal glands, so that a matting of all the parts take-. 
place, the edges of the lungs, pericardium, and great vessels being firmly bound 
together. The pericardium may be adherent to the walls of the heart, there 
may be extensive pleuritic adhesions of one or both lungs, and the adhesions 
in some cases are tough and firm and of almost cartilaginous hardness. 

The etiology of these cases is uncertain. Many cases are associated with 
chronic tuberculosis of the lung or with caseous mediastinal glands ; in 
others no evidence of tubercle can be found, a simple chronic inflammation 
of the connective tissue going on, ending in cicatrisation. The immediate 
result of this process is to hamper the action of the heart, preventing its 




Fig. 80. —Chronic Mediastino-pericarditis. Boy 13 years (see case, p. 419). Ihe anterior 
edges of the lungs were adherent ; in front there were indurated adhesions in the anterior 
mediastinum. 



complete systole, to interfere with the filling of the lungs during inspiration, 
and to compress the large veins entering the chest. The liver becomes 
constantly engorged, the hepatic system of veins dilated, and a perihepatitis 
results. 

Symptoms. — The course of this curious affection is very chronic. In 
well-marked cases the symptoms are those which are likely to be caused by 
an obstruction to the flow of blood into the chest. Dyspnoea on exertion, 
cyanosis of the face, clubbing of the fingers, distension of the veins of the 
neck, chest, and abdomen during inspiration, and, later, cedema of the face, 
arms, feet, and abdomen. There may be signs of pulmonary tuberculosis 



Mediastino-pericarditis, Pleuro-pericarditis 419 

The 'pulsus paradoxus' — i. e. the pulse becoming smaller during inspiration 
— may be present, but certainly it is absent in some cases. In other cases 
the most marked symptom is ascites, with an enlarged liver, suggesting a 
primary cirrhosis of the liver ; such cases are exceedingly chronic, and they 
improve if the fluid in the abdomen is removed by tapping, and will go on 
for months or even years ; gradually the portal obstruction becomes greater 
and the patient dies of exhaustion. The spleen does not appear to enlarge 
in these cases as it does in primary cirrhosis of the liver. 

The following case may be taken as an example of this affection, running 
an acute course : 

Mediastinals, Ascites. — John E., aged 2 years. Admitted September 9, 1891. 
Mother states that her first five children are dead. No history of syphilis ; patient had 
convulsions at six months of age. Last May he had a cough and was attended by a 
doctor. A month later his abdomen began to swell, and soon after his feet ; this has 
gradually increased. On admission his face is puffy, the abdomen is distended with fluid, 
his legs are much swollen. Temperature 101 , pulse 130, respiration 40. Lungs. — There 
is some diminished resonance over the right upper lobe in front ; over both lungs there 
are fine bubbling rales. Heart. — Apex beat in third interspace sounds normal. Abdomen 
is greatly distended, dulness in both flanks and in epigastrium, thrill plainly felt. Liver. — 
Edge not readily felt, spleen cannot be felt. September 10. — Temperature is 103°, varies 
from 99 to 103 . Crepitation in lungs on both sides. September 14.— Child evidently 
dying ; abdomen relaxed ; edge of liver, both right and left lobe, felt below umbilicus ; a 
nodule about the size of a marble felt in the left lobe. Temperature io5°-io6° before 
death. Post-mortem. — Lungs not adherent ; right lower lobe semi-solid with pneumonia ; 
upper lobe of left solid with graines jaunes, but no tubercle. Much yellow fluid in 
abdomen and some lymph on liver, spleen, diaphragm, and great omentum. Heart not 
enlarged ; pericardium thick and adherent, but can be peeled off, leaving a granular sur- 
face adherent to the diaphragm. In the middle and posterior mediastinum there are 
enlarged glands and much fibrous tissue. The glands are enlarged and caseating, one the 
-size of a filbert, several with putty-like contents. Abdomen.— Eymph and tubercle between 
liver and diaphragm, some lymph on surface of liver. Liver much enlarged and granu- 
lar, one boss the size of a marble on the anterior surface of right lobe near broad ligament, 
creaks when cut, section nutmeg appearance. Spleen enlarged, distended with blood. 
Kidneys pale. 

Chronic indurative Mediastinitis. — James R. , aged 13 years, admitted October 29, 1896. 
History imperfect. Mother states he has had an enlarged abdomen for a year, which she 
attributes to scarlet fever. When admitted the boy was suffering from dyspnoea, cyanosis, 
and ascites. The abdomen was tapped and 251 oz. of fluid removed. An examination 
of the chest showed dulness at both bases behind, and weak breath sounds, much dulness 
over region of the sternum, the heart's impulse could not be seen or felt, but the sounds, 
which were faint, but normal, were best heard just outside and below left nipple line ; 
dulness extends § in. to right of the sternum. Edge of liver felt 2^ in. below the ribs, 
spleen not felt, enlarged veins in the neck. Pulse diminishes during inspiration on both 
sides. Much relief to all the symptoms by tapping. November 14. — Fluid has been 
re-accumulating, dyspnoea urgent, 280 oz. removed by tapping. February 24. — Fluid has 
been slowly accumulating, boy keeping better on the whole. To-day there is a purpuric 
rash on body and limbs, and a swelling, apparently a periosteal haemorrhage, over both 
forearms ( ? ulna). February 26. — Synovitis of both wrists and finger-joints, and also 
shoulder-joint, with temperature of 99°-ioo° F. March 2. — Joints better, much dyspnoea, 
friction sounds over bases of lungs, more dulness than when admitted. Dyspnoea urgent. 
Death March 9. Post-mortem. — Lungs. — Old adhesions, especially right along the 
anterior edges, fixing them to the anterior mediastinum, bases adherent to diaphragm, 
both bases behind pleura thickened and white, resembling ' porcelain ; ' the thickened 
pleura has contracted the lungs. Some recent pleurisy. Section tough and gorged like 
" heart ' lung. Heart. — Much fibroid material in anterior mediastinum (fig. 80). Pericarditt?n 

E E 2 



420 Diseases of the Circulatory System 

thickened and adherent to surrounding parts, adherent to ln-art walls. Heart small, wall 
thin, no dilatation, no endocarditis. Muscle easily tears. Aorta admits forefinger, valves 

healthy. Superior vena cava dilated, but surrounded and fixed by indurated tissues 
in the mediastinum. Peritoneum. — Much ascites, no lymph. Liver capsule thickened, 
din icnt to diaphragm, but can be separated. Capsule looks like 'porcelain,' with a 
number of holes through it showing liver surface. Section of liver shows the thi< I 
capsule has rounded off the edges of the liver, tying it up into a ball. Hepatic veins 
dilated, section like ' nutmeg,' no cirrhosis. Spleen enlarged, capsule thickened and 
' porcelain '-like. Kidneys normal. No tubercular disease anywhere. 

Raynaud's Disease — Paroxysmal Haemoglobinuria 

About one-fourth of the cases of Raynaud's disease reported occurred in 
children under ten years of age (J. E. Morgan). Concerning the etiology of 
this disease nothing is known ; in some cases there is a history of malaria, 
but certainly in many of the reported cases there was no such connection. 
In some cases haemoglobinuria has been a prominent symptom, and it is 
believed by some (Dickenson, Abercrombie) that paroxysmal haemoglobinuria 
is a part of the more general disorder which may or may not be present. 

The first symptoms of Raynaud's disease may appear as early as the end 
of the second year, the friends noticing that the child's hands or feet after 
exposure to cold become numb and blue ; the ears and cheeks may become 
easily affected. Before an attack comes on, there is shivering and perhaps 
crying with pain or discomfort. In more severe cases the hands and feet are 
swollen and of a dark-blue colour. In some of the cases after the attack is 
over the child passes urine containing albumen and haemoglobin (J. Aber- 
crombie). In other cases no abnormal urine is noted. The exciting cause 
of the attack in all these cases is exposure to cold ; the attacks are commoner 
in the winter, and when occurring in the summer the attacks follow a cold 
bath or a chill of some sort. In mild cases the attack does not last long ; if 
warmth is applied the blueness and numbness pass off in the course of half 
an hour or less. 

While such is the common type of attack in Raynaud's disease, it happens 
at times that the numbness or blueness of the extremities ends in gangrene 
and spontaneous amputation. A typical case of this kind is recorded by 
Harold (La?tcet, February 9, 1895) of a weakly boy of four years of age ; both 
hands and feet were affected. The hands and feet were blue and numbed, the 
hands recovered, but the feet beginning at the toes became gangrenous, and 
a spontaneous amputation of both feet gradually occurred. The boy eventu- 
ally made a good recovery. In these cases there is no doubt a stenosis or 
narrowing of the arteries to the limb or the capillary arteries are affected. 
All children who are liable to these attacks obviously require the greatest 
care in the avoidance of cold, and possibly during cold weather have to be 
confined to bed, or at any rate to one room. The treatment is the treatment 
of symptoms. 



421 



CHAPTER XIX 

DISEASES OF THE CIRCULATORY SYSTEM — continued 

Naevus. — Naevus is perhaps the commonest congenital disfigurement 
met with in children ; 1 usually it is nothing more than a blemish, though 
occasionally it becomes more serious, either from danger to life or serious 
interference with its subject's welfare. Naevi are probably always congenital, 
though not always noticed at birth, since they may not be large enough to 
be conspicuous until some time later. 

Naevi belong to the class of the angiomata, and are defined as 'tumours 
consisting of newly formed blood-vessels,' though it is obvious that they are 
not always tumours in the sense of their being any definite mass of tissue— 
e.g. ' port-wine stains ; ' still this is merely a question of a diffuse as con- 
trasted with a circumscribed growth. 

These growths may be classified as — 

I. (a) Simple angioma^ telangiectasis, congenital naevus, mother's mark or 
port-wine stain. The vessels composing the new formation are identical in 
structure with normal arteries, veins and capillaries, (b) Cavernous a?igioma, 
lacunar or erectile angioma. The blood circulates in a lacunar system as in 
normal erectile tissue. (Cornil and Ranvier.) 

II. Naevi may be considered as (i) arterial, (2) venous, (3) capillary, 
(4) lacunar, blood-vascular growths. 

III. Or, considered from their locality, the naevi may be divided into 
(1) cutaneous : (a) a mere staining or port-wine mark, (b) a distinct mass 
with larger vessels. (2) Subcutaneous. (3) Mixed — i.e. both cutaneous and 
subcutaneous. The different forms of naevi are readily distinguishable. 

Stellate Naevus. — The so-called ' stellate ' or ' spider' naevus, which is 
doubtfully a new formation, and very probably only a dilatation of pre- 
existing vessels, resembles in appearance the venae stellatae on the surface 
of the kidney of a carnivore. It is most common in the face, disappears on 
pressure, and is closely allied to the mere weather marks of those exposed 
to wind and cold ; it is sometimes seen about the faces of children. 

Port-wine marks consists of a diffuse stain, varying much in size, form, 
position and colour ; usually there are no obvious dilated vessels, though these 
can be made out on more minute examination. These marks occur, perhaps 

1 Depaul is quoted by Cornil and Ranvier as saying that one-third of the children 
born at the Clinic of the Faculty of Medicine in Paris have naevi, and these mostly dis- 
appear spontaneously during the first few months of life. 



422 



Diseases of the Circulatory System 



most commonly on the face, often on the hands, and occasionally else- 
where ; they may cover very large surfaces, such as the whole side of the 
face. There is no elevation of the growth above the level of the skin, only 
the superficial layers of which are involved, and pressure completely obli- 
terates the stain for the time. 

Cutaneous Naevus. — The common cutaneous naevus is usually small, 
not covering more than a square inch of surface at most ; it is somewhat 
raised above the level of the surrounding skin ; the individual vessels can 
often be distinctly made out, though not always ; the colour of the growth is 
usually vivid red, and on pressure the colour and much of the swelling dis- 
appear, but a slight thickening remains and the skin is ' granular.' 1 These 

growths lie in the corium, and are 
usually sharply defined, but not en- 
capsuled. 

Subcutaneous Naevus. — The 
growth lies entirely beneath the co- 
rium, and forms a distinct tumour ; 
the skin over it is natural in colour, 
or only shows a faint bluish tint ; the 
swelling does not entirely disappear 
on pressure, and is often encapsuled 
more or less perfectly. 2 

Mixed Naevus. — This is a com- 
moner form than the last ; it has the 
characteristics of the cutaneous and 
subcutaneous varieties combined — 
i.e. there is a subcutaneous naevus 
with a cutaneous patch on its sur- 
face ; corium and subcutaneous tis- 
sue are both involved. It is seldom 
that the cutaneous part is as exten- 
sive as the subcutaneous, and in this 
and the last form there is often some 
cavernous formation. 

After removal from the" body and 
escape of its blood, a subcutaneous or mixed naevus consists of a tough, 
spongy, or stringy mass, often somewhat lobulated, and always much smaller 
than might be expected from its size before removal. If encapsuled, it will 
be found that only a small number of vessels, and those of considerable size, 
feed the growth and enter it at various parts — a very important fact as regards 
the treatment of these cases. 

Simple Naevi consist of newly formed vessels having the structure of 
capillaries, and presenting ampullar or cirsoid dilatations ; the vessels are 
supported by a framework of connective tissue, and often fat. 

Cavernous Naevi consist of an irregular network of fibrous tissue, in- 
closing freely intercommunicating spaces like the channels in a sponge ; there 

1 Sir J. Paget. 

2 A good account of the structure of naevi will be found in Cornil and Ranvier's 
Histology, to which we are indebted for part of our description. 




Fig. 8i. — Extensive ' Mixed ' Naevus of the Face, 
involving the lower lip and both cheeks up to 
the ears. 



Ncevus 



423 



is occasionally unstriped muscular fibre developed in the septa, as well as 
vessels and nerves. The endothelium lining a naevoid lacuna is exactly like 
that of a vein. These naevi are formed by dilatation of newly developed 
capillaries and subsequent absorption of their barrier walls, so that free 
openings are made between adjacent vessels. 

Importance of Ncsvi. — Usually naevi are simply disfigurements ; some- 
times, however, they may give rise to serious bleeding from rupture of vessels 
by injury or ulceration, as in a case of our own where the soft palate and 
uvula were the seat of a large naevoid growth and frequent bleeding occurred ; 
similar trouble has been met with in the case of rectal naevi. Internal naevi 
may possibly be dangerous from hcemorrhage, or from extravasation of blood 
setting up peritonitis, &c. ; but 
this must be very rare. Some 
very extensive naevi are of im- 
portance from interference with 
the action of the muscles or the 
growth of bones, or from pro- 
ducing unwieldy hypertrophy of 
skin. We have seen fracture 
of the thigh due to weakening 
of the femur from an extensive 
naevus growth in the limb. 1 Un- 
wieldy overgrowth of limbs may 
occur also from the presence of 
naevi ; and in the case figured 
(fig. 82) the man was unable to 
obtain work on account of his 
disfigurement. We have seen a 
case of pyaemia having its origin 
in a suppurating naevus, and 
another where pyaemia followed 
puncture and partial removal of 
a naevoid growth. 

Changes occurring in Ncevi. 
Naevi sometimes grow rapidly 
from the first and spread over considerable areas ; in many cases, however, 
they grow very slowly, alternately grow and remain stationary, or disappear 
altogether, the last result being especially common in the cutaneous form. 
As Mr. Holmes and others have pointed out, and as we ourselves have seen, 
an illness, especially apparently whooping cough, often seems to bring about 
the cure of a naevus ; possibly the straining in coughing may produce extra- 
vasation and thrombosis in the naevus, and so obliteration. 

Naevi undergo spontaneous cure by fibroid change, the vessels becoming 
obliterated and shrinking into fibrous cords. Such result may follow treat- 
ment or accidental irritation by friction of the clothes, or pressure in lying, 
and so on. In other instances calcareous degeneration or thrombosis takes 
place. Cystic change in naevi is very common ; the cysts contain serum, 

1 The patient was under the care of our colleague, Mr. T. Jones. 




Fig. 82. — Naevus of the face in a man of 50. The 
growth was steadily but slowly increasing. The whole 
skin of that side of the face was deep crimson, the lip 
and tongue were involved, and the lower jaw distorted 
and everted by the weight of the enormous lower lip. 
The man died of aortic aneurism. The specimen is 
in the Owens College Museum. 



424 Pi senses of the Circulatory System 

more or less deeply coloured, and arise from the shutting off of a lacunar 
space or dilated vessel from the blood stream ; the cystic is often combined 
with the fibrous and fatty degeneration. 

Suppuration and ulceration of a naevus is an important condition ; for, 
on the one hand, it may produce a cure by obliteration of the vessels, or, on 
the other hand, as already pointed out, septic absorption or bleeding may 
result ; happily obliteration is the common termination. Various combina- 
tions of these changes may be found going' on in a naevus at the same time ; 
pigmentary changes are also found, and sometimes an overgrowth of hair, 
especially in the lipomatous form {vide p. 428). Mere pigmentary maculae 
are sometimes called naevi, but it is better to restrict the name to the vascular 
growth. 

Sites of Ncevi. — Naevi may be found almost anywhere over the body, but 
there are certain markedly favourite positions. External naevi are most 
common on the head, and of all places we should say the most frequent is 
over the anterior fontanelle ; the lips, nose, cheeks, eyelids, or any part of the 
face may be involved. The trunk and limbs are less commonly affected 
than the face, but perhaps this is partly to be accounted for by the mothers 
being less anxious about naevi on the body ; the labia are not uncommonly 
affected. We have seen a case in which most alarming growth of the naevus 
took place during pregnancy ; subsidence of the swelling followed delivery. 
Different forms of naevi often occur in the same patient — e.g. a port-wine 
mark on the face or hand and a mixed naevus on the scalp. Naevi occurring 
inside the mouth, in the cheeks, tongue, or inner surface of the lip, more 
rarely in the palate, are of course more serious than external ones ; they are 
also much less common. 

Visceral naevi are often seen on the liver, and less often on the kidneys, 
spleen, and other organs ; the muscles and bones are also sometimes affected. 
It is common to see naevi on the skin of meningoceles both cerebral and 
spinal— a fact noticed by Mr. Holmes, and one of some importance from a 
diagnostic point of view. 

Several cases of rectal naevi are on record, among others one mentioned 
by Mr. Barker which caused death by haemorrhage. 1 We have met with a 
case which exactly simulated piles, and was cured by ligature. The extent 
of tissue involved is sometimes very great, as already stated ; thus we have 
seen the whole lower extremity naevoid, and Mr. Barker has recorded a case 
of the whole upper extremity being so affected 2 {vide also fig. 82). 

Treatment of Ncevi. — It should be a rule of practice not to interfere with 
naevi unless they are growing or have been stationary for some time, since, 
as already pointed out, very many disappear of themselves. The important 
points to consider for each naevus are whether it is cutaneous, subcutaneous, 
or mixed, and what is its relation to important adjacent structures, which 
may be endangered by treatment or by the resulting scar, It is unnecessary 
to mention all the methods proposed for treating these growths ; only the 
most efficient will be described here. Stellate naevi may readily be cured 
by puncturing the centre of the star with a hot needle. Port-wine marks 
require careful consideration as to whether the resulting white scar will not 
be as disfiguring as the red mark, and it must be remembered that in cases 
1 Brit. Med. Jour. 1883. - Clin. Soc. Trans. 1884. 



Ncevus 425 

where a large surface is involved a long course of treatment is required to 
remove the mark. 

Linear scarification, multiple puncture, the actual cautery or a caustic 
such as fuming nitric acid, and in some cases electrolysis, will succeed. 
From five to twenty or more cells of a Stohrer's or Weiss' battery should be 
used If large, the patch should be treated in sections, so as not to have too 
large a sore surface at once. 

Cutaneous naevi are best treated with the actual cautery ; if small, a heated 
needle is sufficient ; in larger growths Paquelin's cautery is the most useful 
instrument. Narrow lines may be scored across and across the naevus, or 
multiple punctures employed ; after using the cautery once, as soon as the 
wound is healed, it will often be found that little patches remain unoblite- 
rated : these should be watched for some weeks before reapplying the cautery, 
as tbey often shrink subsequently without further operation. The cautery 
should be at a dull red heat, and should be applied deeply enough to reach 
through the naevus. Ethylate of sodium is fairly efficient, but usually requires 
several applications, and is not, we think, better than the cautery ; it has the 
advantage of not requiring the use of an anaesthetic, though it is followed by 
a good deal of temporary smarting. For port-wine stains the ethylate may 
be applied every two or three days according to the effect produced, and 
then, if required, fresh applications may be made after two or three weeks. 
Vaccination on a naevus is not a good plan. For subcutaneous or mixed 
naevi we cannot recommend injections of any kind ; they are often efficient, 
but always dangerous, extensive thrombosis or embolism, causing immediate 
death, having followed their use ; if they are employed, a temporary ligature 
should be put round the naevus and removed a few minutes after injection. 
Ligature of naevi is uncertain, as well as tedious and troublesome. We think 
treatment by excision, by multiple puncture with the cautery, and in suitable 
cases by electrolysis, are the most generally useful methods. 

Excision is applicable to well-encapsuled growths of small or moderate 
size, not involving important structures. There are certain essential points 
in the operation : first, the incisions must be carried well wide of the growth 
and not within its capsule ; there will then be only a few well-defined vessels 
to secure, and not a freely bleeding cavernous tissue, as is the case if the 
growth is cut into ; next, the skin in a mixed naevus, if the cutaneous part 
is very small, should be removed as far as it is involved, provided always 
the edges of the wound can afterwards be brought together easily so as to 
obtain primary union. If the skin is widely involved, it should not be taken 
away, but, as suggested by Mr. Teale, dissected off the naevus and pre- 
served ; this, however, necessitates opening up the naevoid tissue, and com- 
plicates the operation : sometimes also the cutaneous naevus continues to grow 
afterwards. 

A bloodless method of excising naevi is that of passing long needles or 
harelip pins beneath the base of the growth crosswise, then winding an 
elastic thread round the needles and excising the growth after dissecting back 
skin flaps ; the needles are then withdrawn and the vessels are secured. 
There is'no bleeding until the elastic is removed. 1 Degenerated naevi should 
nearly always be excised if they are treated at all ; in some instances, where 
1 A plan devised, we believe, by Mr. Davies Colley. 



426 Diseases of the Circulatory System 

there is cystic degeneration, a seton passed through the cyst causes it to 
shrink ; but there is a certain amount of danger in this plan if any part of the 
naevus remains undegenerated. 

The little galvano-caustic apparatus devised by Mr. Golding-Bird for 
enucleating lymphatic glands we have used with good effect for large mixed 
naevi not removable by excision. 

In using the actual cautery the fine or middle-sized point of the Paquelin's 
cautery is entered through the skin and made to traverse the naevus in 
several directions from one puncture ; if the naevus is large, this is repeated 

at another spot, and so on ; a 
little boric acid ointment is then 
applied to the cauterised surface 
and the effect is watched ; after 
all contraction has ceased another 
portion is, if necessary, attacked, 
until the whole mass has shrunk. 
Pressure is occasionally suc- 
cessful as a means of treating 
naevi, but is chiefly applicable 
to cases where other treatment 
is impracticable, as in very ex- 
tensive naevus of a limb ; ! it 
may be employed successfully 
sometimes in naevus of the scalp, 
where the underlying skull forms 
a firm basis ; especially if com- 
bined with subcutaneous break- 
ing up of the naevus with a 
tenotome. In cases of ulcera- 
tion of naevi, and in some severe 
cutaneous forms, scraping away 
the growth with a sharp spoon 
will sometimes do good. 
Importance of Ncevi i?i special Localities. — Naevi occurring in certain 
localities have more than ordinary importance, either from the difficulty of 
their treatment or diagnosis or from the risk attaching to them. Naevus of 
the lip is often found involving the whole thickness of either lip, and is 
usually either of the mixed or subcutaneous variety ; the surface is some- 
what prone to ulceration in the mixed form from constant irritation, and 
the growth is often very unsightly. If degenerated and cystic, or if there 
are large cavernous spaces in the naevus, it may be mistaken for a labial 
mucous cyst or for lymphatic macrocheilia. Puncture from the mucous 
aspect with the Paquelin's cautery is usually the best mode of treatment, 
but in some cases it is a good plan to excise a segment of the lip and 
bring the edges together as after a harelip operation. Orbital naevi are 
usually associated with similar growths upon the face : they may cause ex- 
ophthalmos and ectropion ; the naevoid character of the growth is indicated 

1 A good case of the effects of pressure under such circumstances is recorded by Hardie, 
Lancet, May 1885. 




Fig. 83. — Orbital Naevus. The growth extended deeply, 
causing exophthalmos and ectropion, and spread up- 
wards upon the forehead. 



Ncevus 427 

by the spongy feeling and the possibility in some cases of pushing back 
the protruding eyeball and so emptying the growth of blood. Treatment by 
electrolysis is the only serviceable method in these cases. 

Naevus of the tongue may give rise to macroglossia and cause protrusion 
of the organ, or may be limited to a small part of its surface ; it is liable to be 
mistaken for lymphatic macroglossia or for a mucous cyst. The colour will 
usually serve to distinguish it from the former, though the two conditions 
seem to be sometimes combined, and the compressibility of a naevus will 
mark it off from the latter affection ; in doubtful cases a grooved needle will 
clear up the difficulty. The actual cautery, or in rare cases excision, of a 
part of the tongue is the treatment required. In one child we excised the 
anterior third of the tongue by a /\ -shaped incision, and brought the sides 
of the wedge together with sutures ; the result 
was good and repair was rapid. A similar 
condition may be met with on the gums or inner 
surface of the cheeks. Sometimes large blood 
lacunae are met with beneath the tongue, look- 
ing like ranula ; the soft palate and uvula are 
also occasionally affected ; in one instance 
where both conditions existed the sublingual 
naevus was cured by the actual cautery, and the 
inula removed by the galvanic ecraseur ; the 
patient was attacked by pyaemia, but ultimately 
recovered completely. 

X nevus of the eyelids must be treated with 
great caution to prevent any subsequent distor- * [ 

tion ; it is best usually to attack small portions Fig> 84.— Arterio-venous varix. 
at a time with the actual cautery and wait until 

cicatrisation is complete before a second application. The same rule applies 
to naevus of the nose, where too vigorous treatment may produce an unsightly 
sharp-pointed, beak-like appearance if the skin is too much destroyed. In 
some instances excision is the better plan. 

Naevi around the orbit are sometimes very difficult to diagnose, especially 
if they are degenerated, and consequently have lost their colour ; dermoid 
cysts, meningoceles, simple serous congenital cysts, and fatty growths should 
be borne in mind as sources of fallacy. In one instance (fig. 83) there was a 
cyst with none of the appearance of a naevus ; on tapping it, altered blood 
escaped, and on incision it was found that the growth was loculated and in 
part solid (i.e. degenerated). A seton was passed through it at last after 
failure of incision and drainage, excision being out of the question, and the 
mass suppurated freely, but unfortunately erysipelas occurred and the child 
died. At the post-mortem the orbit and cavernous sinus were found full of 
more or less degenerated naevoid tissue ; the naevus spaces were mostly full 
of blood, and minute abscesses were seen with the microscope in sections of 
the growth. 

Speaking generally, most naevi can be recognised by the presence of the 
remains of some superficial naevoid tissue, by the possibility of reducing the 
size of the growth by pressure — this point must not, of course, be allowed to 
mislead in swellings about the head or spine — and by the peculiar spongy 




421 



Diseases of the Circulatory System 



feeling. This sensation is sometimes to be felt in a growth where solid 
masses are also perceptible. The fact that the tumour is congenital or has 
been noticed in very early life, and occasionally the presence of extravasa- 
tion of blood in the skin, as well as, of course, the results of tapping, will 
usually clear up a doubt. 

Certain rare forms of vascular deformity are occasionally met with in 
children. In a case of our own the condition may be best described as 

arterio-venous varix, all the vessels being 
dilated and pulsatile ; the facial, orbital, 
and intracranial vessels were involved 
as well as some of the cerebral sinuses, 
the straight sinus being converted into 
a pouch as large as a thrush's egg and 
its walls calcified 1 (fig. 84). 

Aneurism by cmastomosis is also oc- 
casionally met with in children, and 
sometimes ligature of a main vessel, 
such as the carotid, may be required, 
as also in some cases of arterial varix. 
St. Germain relates three cases of cirsoid 
aneurism cured by the use of chloride 
of zinc arrows. ( Vide ' Chirurgie des 
Enfants,' 1884.) Excision is usually the 
best treatment. 

Ncevus lipomatodes is the term ap- 
plied to a form of degenerated naevus 
in which there is much development of 
fatty tissue forming masses which often 
hang in pendulous folds ; there is com- 
monly pigmentation and hairy over- 
growth. The condition is rare, and 
appears to be associated with idiocy, 
as in the typical case under our care, 
from which fig. 85 was taken. No 
treatment is called for in such a case. 2 
We have recently (1895) seen a female 
infant a few weeks old with an almost 
exactly similar condition. Occasionally, 
however, where merely a local mass is 
found, it should be removed by excision. 
This was the treatment adopted for 
86, where the pendulous hairy mass, closely 
'pachydermatocele,' was excised with a good 




Fig. 85. — Naevus Lipomatodes. The darkly 
pigmented pendulous masses were com- 
posed of fat and degenerated naevus tissue, 
and the whole surface was thickly over- 
grown with hair. As usual in these cases, 
the child was idiotic. 



the child shown in fig. 
resembling the so-called 
result. 

Lymphatic Naevi. — Lymphatic naevi are much rarer than blood naevi, 
but many of the so-called congenital cystic growths should be classed as 

1 A full report of the case here alluded to will be found in the Abstracts of the 
Children's Hospital for 1882-83. Vide also T. Smith, Clin. Soc. Trans. 1882. 

2 Hyde of Chicago has recorded a very similar case in the Lancet, August 1, 1885. 



Ncevus 



429 



cystic lymphangiomata. Instances of this condition are seen, as shown by 
Virchow, in macroglossia, described at p. 176. 

Hygroma and one form of so-called ' giant foot ' are similar conditions 
(fig. 87). Sometimes in giant foot the cutaneous lymphatics are clearly visible 
as transparent, dilated, tortuous canals running in the skin : the part is greatly 
enlarged, and spongy on pressure. The disease is a rare one, and probably 
pressure or cautery puncture would be the most successful mode of treatment. 
Treves has recorded a case in which ulceration has occurred, and quotes 
Busey that congenital giant foot is commoner in females, and most frequent 
in the right leg ; the temperature of the part may or may not be raised. 
Ulcers, if they occur, readily heal. 

Occasionally in macroglossia, as in a case of ours, the superficial lym- 
phatics form minute transparent cysts on the surface of the tongue ; here 





Fig. 87. — Lymphatic Ncevus of the 
Foot. The soles of the two feet are 
seen, and in the affected one the 
extremities of the toes can just be 
made out, embedded in the mass of 
naevus tissue. Dilated and varicose 
lymphatics were visible in the skin. 



Fig. 86. — Degenerated Naevus of Scalp. 

removal of part of the tongue might possibly be required to prevent suffocation, 
since these growths are liable to rapid increase in size. A large tumour of the 
thigh, of congenital origin, that we removed a short time ago from a child of 
2\ years, was made of spongy tissue exactly like a naevus, but the spaces 
were filled with lymph instead of blood ; other similar cases have been 
recorded. ( Vide also chapter on Tumours.) Hoggan has described multiple 
lymphatic naevi of the skin, a condition believed commonly to accompany 
blood naevi, and to be much more frequent than is supposed ; these growths 
are not conspicuous by their colour, and are therefore commonly overlooked ; 
they are of little clinical importance, unless probably as an early stage of 
elephantiasis. We have also met with instances of these naevi. 1 Cases of 
1 Hoggan, Jour, of Anat. and Phys. April 1884. Lancet, 1882, vol. ii. p. 891. 



43Q 



Diseases of the Circulatory System 



probably congenital lymphatic varices of the limbs have been described by 
R. W. Parker ; he thinks they have a tendency to become locally inflamed. 1 
We have recently met with a case of lymph naevus of the conjunctiva and 
supra-orbital region, causing an unsightly deformity ; the naevus varied much 
in size, and sometimes ' puffed up' and became painful. - 

Large multilocular cystic swellings may be met with in the neck, re- 
sembling in external appearance the hygromata which are associated with 
lymphatic macroglossia, but differing from these lymphatic tumours in that 
some of the cysts are found filled with blood either coagulated or more or 
less altered, and become ' laky.' In the same swelling cysts may contain 
fluid, clear or only tinged with blood. It is difficult in such cases to be sure 
whether the growth is a blood naevus which has undergone cystic degenera- 
tion, or a lymph naevus in which haemorrhages have taken place. Such a 
case which we saw with Dr. McNicoll, of Southport, occurred in a child of 




-Gangrene of the leg secondary to embolism of femoral artery, 
with mitral and aortic disease. 



Boy, aged 7 years, 



seven weeks old ; and as it was growing and threatened to cause dyspnoea, it 
was treated by laying open and partly removing the larger cysts. The opera- 
tion, though extensive and formidable for so young a child, had a satisfactory 
result. 

Excision of the greater part of the cyst wall with subsequent drainage is, 
we have found, the best treatment. If the drain is removed too soon and 
insufficient irritation is set up, the lymph cavity is apt to refill. 

Aneurism in children is extremely rare ; only a few cases have been 
recorded, and these appear all to have been either traumatic or the result 

1 Vide also chap, on Tumour Growths in Childhood. 

2 The case, with a drawing, has been published by Dr. Mules in Trans. Ophthalm. 
Cong. , Heidelberg, 1888. For an account of various rare abnormalities of the blood and 
lymph vascular systems (also Nerven-Naevus , &c.) the reader is referred to Esmarch and 
KulenkampfFs monograph on Elephantiasis. 



A neurism — Embolism 4 3 1 

of embolism, the embolus giving rise to softening of the arterial coat, and con- 
sequent formation of the aneurism. A paper on this subject by R. W. Parker in 
the ' British Medical Journal,' 1884, may be consulted. We have only met with 
one case of aneurism, in a child aged seven years, who was suffering from 
ulcerative endocarditis ; the aneurism, which was situated on the left middle 
cerebral artery, was no doubt due to an embolus ; it finally ruptured and gave 
rise to extensive meningeal haemorrhage. Dr. A. Jacobi has reported several 
cases of aneurism in children, due to atheromatous degeneration, one case 
of the descending aorta in a girl of seven years. Sanne has reported four 
cases, one in a fcetus, and three in children of two, ten, and thirteen years 
respectively. 

Embolism occurs not infrequently during early life in children suffering 
from acute or malignant endocarditis ; it may occur in any form of valvular 
heart disease. Embolism of a cerebral artery may give rise to hemiplegia 
and softening (see p. 409). Embolism of the spleen is found not unfrequently 
post mortem. In a patient of our colleague Dr. Hutton, who was suffering 
from mitral and aortic disease, embolism of the femoral artery occurred 
followed by gangrene of the leg. The leg was amputated by Mr. Collier 
and the boy made a good recovery as far as the stump was concerned. 



432 Diseases of the Blood and Blood-making Organs 



CHAPTER XX 

DISEASES OF THE BLOOD AND BLOOD-MAKING ORGANS 

Anaemia 

Children of all ages are liable to suffer from anaemia, from causes both 
known and -unknown. Some children are habitually pallid, without, perhaps, 
being in any way out of health ; and this peculiarity seems to run in families. 
In the majority of cases anaemia means ill health, the poorness of blood being 
due to one or other of a great variety of ailments. It is unnecessary for 
us to describe the anaemia which is due to obvious causes, such as tuberculosis, 
heart disease, syphilis, malaria, or the anaemia which is the result of some 
acute disease. We will chiefly confine our remarks to certain forms in which 
the anaemia is often profound and the pathology by no means certain. A 
slight acquaintance with the forms of anaemia from which children suffer will 
be sufficient to convince anyone that there are different forms of diverse groups. 
Thus we have anaemia accompanied by great enlargement of the spleen, and 
an anaemia in which no such enlargement is present. We have the so-called 
Pernicious Anaemia, which appears always to go on to a fatal issue. In some 
cases there is a tendency to purpura, and while in all forms of anaemia 
haemorrhages are common when the anaemia becomes extreme, yet in some 
cases purpura is an early symptom, and makes its appearance without the 
anaemia being very great. The groups into which we divide these cases are 
selected rather for convenience of description than from their actually form- 
ing independent or ' self-standing forms ' of disease. 

It is unnecessary to say that an examination of the blood gives important 
information with regard to the nature of the anaemia, and is therefore of use 
as regards prognosis and treatment. For the details of the methods of this 
examination we must refer the reader to the various clinical manuals. 1 

The examination includes (i) The estimation of the amount of haemo- 
globin present as measured by Fleischl's haemometer. In healthy children 
there may be 85 to 95 per cent., in profound anaemia as little as 30 to 35 per 
cent. 

(2) Counting the number of the red and white corpuscles, by means of 
the Thoma-Zeiss apparatus. In round numbers in healthy children there are 
five million red corpuscles to the cubic millimetre ; in some forms of anaemia 
the number may sink to two millions. The number of white corpuscles varies 
from 8,000 to 9,000 (Limbeck) in children, and from 12,000 to 13,000 
(Gunrobin) per cubic millimetre in infants under a year. 

(3) A microscopical examination [of the red corpuscles to determine their 
shape, size, and colour. In extreme forms of anaemia there may be some 

1 Or see Kanthack ' On Blood Changes in Diseased Conditions,' Medical Chronicle, 
July, August, October 1894. 



Ancemia 433 

nucleated red corpuscles present, and the corpuscles may be misshapen and 
very pale. 

(4) A film of dried blood is stained with eosin and methyl blue in order 
to distinguish between the varieties of white corpuscles present, and to de- 
termine their relative proportion. Following Ehrlich's methods, Kanthack 
distinguishes the following varieties : 

(a) lymphocytes, consisting of small cells with a large blue nucleus and 
narrow zone of clear protoplasm ; they are supposed to derive their origin 
from lymphatic gland tissue, (b) large uninuclear cells, consisting of 
cells with a large oval or indented nucleus, and a large zone of surrounding 
clear protoplasm. They are supposed to be derived from the marrow of 
bone and spleen. (c) Finely granular or polynuclear (neutrophile cells. 
The nucleus is multipartite, and lobed. The protoplasm is filled with granules 
which stain with eosin. The number of these cells is increased in febrile 
conditions : they are in normal conditions in adults the most numerous of 
the white corpuscles present. {d) Coarsely granular eosinophile cells : 
they have a single round or horseshoe nucleus, the protoplasm has coarse 
granules which stain strongly with eosin. 

As regards the relative numbers of these in the blood of healthy adults 
and infants, the following numbers may be taken as approximately true. 
Lymphocytes, adults 20 per cent., infants under one year 59 per cent. 
Large uninuclear cells, adults 6 per cent., infants 6 per cent. 
Finely granular neutrophile cells, adults 75 percent, infants 31 per cent. 
Coarsely granular eosinophile cells, adults 2 per cent., infants 3 per cent. 
(Uskoff), (Gunrobin). 

From this it would appear that in early life the lymphocytes are increased 
at the expense of the finely granular or neutrophile cells. 

Anaemia with (Edema. — In all cases in which the anaemia is great there 
is a tendency to the accumulation of serum in the serous cavities, and a 
liability to subcutaneous cedema. In the out-patient department of hospital 
practice it is common to meet with infants or children under two years of age 
who are anaemic, and at the same time cedematous, the back of their hands 
and feet readily pitting. Such cases are often looked upon as suffering 
from nephritis, but the urine is mostly free from albumen and casts. There 
is usually no enlargement of the spleen. These cases are commonly seen in 
the autumn in children who have suffered from acute diarrhoea or some other 
exhausting disease which has given rise to great anaemia. The anaemia is 
due to the great drain on the system during acute or long-continued disease, 
or possibly it may be the result of the action of toxic albumens or peptones 
absorbed into the blood from the alimentary canal. We must also remem- 
ber that the arterial pressure in young children is normally very small, and 
easily reduced by acute disease. (See Nephritis.) 

Simple Anaemia — Chlorosis.- — -There is a class of case mostly occurring 
in older children which resembles the chlorosis of adults. There is no 
enlargement of the spleen, no purpura or any evidence of organic disease. 
The children are markedly bloodless, languid and easily get out of breath ; 
murmurs may be heard at the base of the heart, and in the veins and arteries 
of the neck. Both girls and boys may be affected in this way about puberty. 
In one instance coming under our notice, two brothers and a sister, aged 8|, 

F F 



434 Diseases of the Blood and Blood-making Organs 

7, and 5f years, suffered in this way ; their mother was also anaemic. They 
were intensely anaemic, and were drowsy and lethargic. They were fairly well 
nourished as far as fat was concerned ; there was no splenic enlargement, 
no albumen in the urine, and no haemorrhages. In all three there was an 
irregular pyrexia, a rise of a degree or two taking place most evenings. An 
examination of the blood showed a diminution of red blood corpuscles, and 
no striking excess of white corpuscles. They all three improved consider- 
ably during their stay in hospital. It is well to bear in mind that such cases 
are exceedingly apt to suffer from tubercle. 

Idiopathic or Pernicious Anaemia is apt to occur in children ; out of 
102 cases published by Dr. Pye Smith in the Guy's Hospital 'Reports' for 
1882 there were six between the ages of seven and fifteen years. It has been 
met with in children of all ages. Kjellberg has recorded a case in a boy of 
five years, Elben in a girl of three years, and W. Steffen in a girl of sixteen 
months. It is always fatal. 

No cause can usually be assigned for the anaemia ; in one case coming 
under our notice the child had been much neglected and badly fed. 
Schapiro reports a case of a girl of 13 years who was supposed to suffer 
from pernicious anaemia, but began to improve after passing a tape-worm — 
Bothriocephalus latus. 

The symptoms and course are exactly the same in children as in adults. 
The first symptoms are those of weakness, breathlessness, and pallor, coming 
on without cause. The anaemia becomes extreme, the skin is blanched and 
of an earthy tinge ; the conjunctivae and mucous membrane of the mouth 
are pallid, and the muscles weak and flabby. Usually there is no great loss 
of flesh. Vomiting is not uncommonly a marked symptom. In some cases 
there appears to be a slight rise of temperature at night, 10 1° or 102 ; in this 
respect pernicious anaemia resembles other forms of anaemia. Purpuric spots 
are sometimes present on the skin, and retinal haemorrhages and optic 
neuritis may take place (S. Mackenzie). 

An examination of the blood in an advanced case shows a very marked 
diminution of the red blood corpuscles without any leucocytosis, indeed the 
white corpuscles are usually diminished, and a considerable number of large 
red corpuscles (megaloblasts) are present. In a case of pernicious anaemia 
which, as we have already remarked, is an exceedingly fatal disease, dia- 
gnosis is of great importance. It is most likely to be mistaken for some form 
of secondary anaemia, in which there has been severe haemorrhage, or the 
feeding has been bad as in scurvy. The following are the chief points to be 
noted in examining the blood. See Kanthack (loc. cit.). 

Chlorosis 
Red blood corpuscles slightly 

reduced in number ; Hb 

considerably reduced. 
Red corpuscles retain their 

size and shape, nucleated 

red corpuscles rare. 
No leucocytosis. 
No large red corpuscles 

present. 



Secondary A ncemia 

Red blood corpuscles re- 
duced ; marked decrease 
of Hb. 

Nucleated red corpuscles 
present ; red corpuscles 
vary in size and shape. 

In acute cases there is leuco- 
cytosis due to an increase 
in the number of the 
polynuclear leucocytes. 

No large red corpuscles. 



Pernicious Ancemia 
Red blood corpuscles greatly 

reduced, Hb diminished, 

but not in proportion. 
Nucleated red corpuscles 

extremely common ; they 

are easily injured. 
No leucocytosis, usually a 

diminution. 
Large red corpuscles are 

present. 



A ncemia — Scurvy 43 5 

The course is often acute, usually varying from one month to three 
months. 

Morbid Anatomy. — All the organs are in a bloodless condition, the 
muscles are in a state of fatty degeneration, and minute haemorrhages are 
found on the surfaces of the organs. There is no further alteration found 
in the spleen or other viscera. 

The following case illustrates many of the above points : 

Pernicious Aneemia. — Walter H., aged nj years, has been getting pale and weak for 
six months, no cause known ; has had hollow cough and frontal headache ; for two 
months has had frequent epistaxis, and for some time has had fainting fits, and spots 
'like bruises' have appeared on thighs and shins; no bleeding from lungs or bowels 
noticed. Mother strong, father said to have been phthisical in early life ; brothers and 
sisters all rickety and anaemic, four of them now in hospital with scarlet fever ; all re- 
covering. Admitted August 30. Large, well-formed, well-nourished, and muscular boy, 
dark brown hair and eyes, height 4ft. 7 in., intelligent, intensely anaemic, tongue furred, 
pale and fissured, fauces pale, tonsils large ; respiration 34, fairly deep ; pulse 146, regu- 
lar and full ; temperature 103 ; both bases dull, with weak respiratory sounds, no crepi- 
tation, heart's area normal, impulse heaving and visible over second to fifth spaces, sounds 
at left base murmurous, spleen and liver not felt in abdomen, blood watery and pale ; red 
corpuscles, generally normal in shape and form characteristic rouleaux, a few are elon- 
gated ; white corpuscles only slightly increased relatively, vary much in size, most of them 
being smaller than usual ; urine 1016, pale, no albumen, no excess of urates or phosphates ; 
ordered citrate of iron. August 31. — Temperature now between normal and ioo°. 
September 6. — Temperature still below ioo° ; respiration 32 ; pulse 148 ; no cough, no 
night sweating, has attacks of syncope on attempting to sit up, has vomited twice to-day, 
no cardiac murmur. Died September 7. 

Post-mortem. — Forty hours after death body well nourished, intensely anaemic, rigor 
mortis persists, a few ounces of serum in each pleural cavity, patches of emphysema 
along margins of lungs, no consolidation, abundant sub-pleural ecchymoses ; about 2 oz. 
clear serum in pericardium, no pericarditis, no endocarditis, abundant sub-pericardial 
ecchymoses, tricuspid orifice admits three fingers, muscular fibre pale ; much ' tabby-cat ' 
mottling of endocardium. Spleen 3^ oz. , soft and friable ; liver 34^ oz. , very anaemic ; 
kidneys \h oz. , very soft, intensely anaemic, capsules peel off readily. 

Baginsky l records a case of pernicious anaemia in a child of 3^ years. It 
suffered from haemophilia for a year before its death. When seen it was very 
pale, the liver and spleen were enlarged. An examination of the blood 
showed only 2,680,000 red blood corpuscles per cubic millimetre, and only 
17 per cent. Hb (Fleischl). The proportion of white corpuscles to red was 
1 in 100. The red blood corpuscles had undergone change of shape ; there 
were megalo-blasts and nucleated red corpuscles, many large uninuclear cells, 
and a small number of the multinuclear. No eosinophile cells. 

Treatment. — The medicines most likely to be of service are iron and 
arsenic. Phosphorus and cod liver oil have been used with some success 
Bone marrow and raw meat juice should be given. In the majority of cases 
the progress is from bad to worse. 

Scurvy. — A scorbutic state may sometimes be met with in children as 
the result- of bad or improper food, especially if fresh vegetables have been 
excluded from it ; such are cases of true scurvy, similar in every respect to 
those which used to occur so frequently among seamen. A similar condition 
is met with in association with certain depressing diseases such as tuberculosis. 
At other times when it occurs it is difficult to assign any cause. 
1 Berliner Klin. Woch. 20, 1894. 



436 Diseases of the Blood and Blood-making Organs 

The patient is usually anaemic, though he may be well nourished as far 
as subcutaneous fat is coneerned ; the gums are spongy and offensive, they 
bleed with the slightest injury, the teeth are loose and may fall out ; haemor- 
rhage is apt to occur from the nose, kidneys, and bowels ; purpuric spots are 
common, and bruising occurs after the slightest injuries. The majority of 
the cases which come under our notice in hospital quickly improve with 
proper dieting and careful nursing. In one of our cases, where a scorbutic 
condition was present in a boy often years in association with fibroid phthisis, 
improvement took place on several occasions when we had him in hospital, 
but he eventually died from exhaustion, the result of frequent haemorrhages. 
At the post-mortem a chronic tuberculosis was found, but nothing was 
found to explain the hemorrhagic condition suffered from during life. (See 
Infantile Scurvy, p. 192.) 

Treatment. — In all cases where there is anaemia, with spongy gums and a 
tendency to haemorrhage, lemon or orange juice should be given, and fresh 
vegetables in some form or other should enter into the diet. Scraped 
underdone meat, beef juice and eggs are also necessary. The gums should be 
carefully cleaned, and painted with glycerine of tannin, borax and tincture 
of myrrh, or some other antiseptic. Iron and cod liver oil should be given 
internally. Haemostatics, such as ex. hamamelis liq., gallic acid, and turpen- 
tine, will often be required. 

Enlarged Spleen 

The spleen is a very vascular organ, is functionally more active in child- 
hood than in after life, and is more apt to become temporarily engorged 
and enlarged. The best method of determining the enlargement during 
early life is by palpation rather than by percussion, as the lesser rigidity of 
the abdominal walls during early childhood usually readily permits of this. 
Palpation of the spleen is effected by standing at the patient's right side 
and gently pressing two or three fingers of the right hand into the left hypo- 
chondrium beneath the costal arch, when the lower and inner edge of the 
spleen, if it is enlarged, can be readily felt as a movable tumour which can be 
pressed upwards. It can hardly be said that the spleen is abnormally en- 
larged unless its lower edge extends below the costal arch. Enlargement is 
very common during childhood, and accompanies various conditions. An en- 
larged spleen is most frequently associated with an anaemic condition, though 
exactly what the relation between the two is is uncertain (see p. 437). An 
enlarged spleen is also met with when the portal system is obstructed, as in 
cirrhosis of the liver. In two cases coming under our notice the spleens 
were greatly enlarged, and in these cases it is quite possible to overlook the 
cirrhosis of the liver and look upon the case as one in which the splenic 
enlargement is due to Hodgkin's disease or some anaemic condition. It is 
enlarged in many cases of rickets and syphilis, though certainly not in all 
cases ; it is chiefly so in those cases in which pallor and anaemia are marked 
symptoms. It is enlarged and hard in ague, and also when lardaceous and 
in association with leucocythaemia and Hodgkin's disease. It is also en- 
larged in various acute diseases, such as typhoid fever, acute tuberculosis 
and pyaemia, and in some other febrile states, such as ulcerative endo- 
carditis. 



Ancemia Splenica 437 

Anaemia Splenica. Anaemia Infantum Pseudoleukemia. — In an 

ill-defined group of cases, occurring mostly in children under two years 
of age, the anaemia is often profound, and the spleen strikingly enlarged. 
Sometimes mothers will bring such children for treatment, as they have 
already noticed the large spleen as well as the paleness of the child. There 
is usually a history to be obtained of ill health, more especially of aggravated 
indigestion, or some acute illness, and nearly all of them exhibit evidence 
of rickety deformities. In a well-marked case, the anaemia strikes the 
observer at once as being much out of the common ; the lips are a 
pale pink, and the face is white or of a slightly yellow tint ; on placing 
the hand on the abdomen, the edge of the spleen is distinctly felt (it can 
sometimes be seen), and the tip can be traced downwards on a level with, 
or below, the umbilicus. There may be enlargement of the liver. The 
urine is free from albumen, and except quite at the termination of the case, 
there are no haemorrhages and no oedema. There is often irregular and 
intermittent pyrexia. The course is essentially chronic ; the patients usually 
improve slowly under treatment in hospital with careful diet and tonic 
medicines. They readily succumb to intercurrent diseases, such as measles 
or pneumonia. In the worst class of case the anaemia becomes more and 
more profound, and they die exhausted ; in the later stages there may be 
haemorrhages, purpura, and oedema. On the other hand, we meet with 
' borderland ' cases, where there is a moderate degree of anaemia and splenic 
enlargements, with perhaps well-marked signs of rickets. The pathology 
of these cases is very obscure ; an examination of the spleen post mortem 
shows it to be hypertrophied, firm, and hard, and on section it is of a dark 
purple colour ; a microscopical examination shows nothing beyond hyper- 
trophy. The etiology of these cases is no less uncertain. The condition 
closely resembles that seen in malaria, but in this country this can be ex- 
cluded with certainty. In a certain proportion of the cases a history of 
syphilis can be obtained ; in thirty cases reported by Carr : there was a 
history of syphilis in eight, a doubtful history in six, and in sixteen no history 
could be obtained. In sixty- three cases reported by Fox and Ball - in forty- 
one per cent, there was a history of syphilis to be obtained. The figures of 
the last observers surprise us ; our experience has been that a definite history 
of syphilis is uncommon, and certainly in a large majority of our cases no 
history of syphilis could be obtained. It is true that syphilis produces both 
anaemia and enlargement of the spleen, especially during the acute phases ; 
but we are not aware of any cases of syphilis having been under observation 
during the acute stage and having then passed into (while under observation) 
a condition of splenic anaemia. That there is a close connection between 
this condition and rickets is certain, as almost all such children exhibit 
evidence of rickety changes in the bones, and this anaemic state occurs 
almost exclusively during the first two years of life, when rickets is most 
common. We are inclined to agree with Carr in believing that, while both 
syphilis and rickets may play a role in producing this condition of splenic 
anaemia, they are neither of them the sole or efficient cause, but that con- 
genital weakness, chronic dyspepsia, bad feeding, and insanitary conditions 

1 Lancet, April 23, 1892. - Brit. Med. Jour. April 1892. 



43 8 P is cases of the JUood and Blood-making Organs 

may interfere with the blood-making organs and lead to a condition of pro- 
found anaemia. 

Hock and Schlesinger x draw a distinction between Ancemia infantum 
pseudoleukemia and Antenna splenica. The first rather awkward-sounding 
name was applied by Jaksch to cases in which there was anaemia, en- 
larged spleen, and leucocytosis ; the latter to a class of case in which there 
was anaemia, enlarged spleen, but no leucocytosis. How far this distinction 
can be maintained we are not prepared to say, but there is a strong pro- 
bability, we think, that there may be different causes at work in producing 
anaemia with splenic enlargement in young children, and we are hardly 
in a position to accord to this class a position among the 'self-standing ; 
diseases. 

In three cases in which the blood was examined by Felsenthal 2 in children 
(ages ten months to one and a quarter years) suffering from well-marked 
anaemia, enlarged spleen, a comparatively small liver, no lymphatic en- 
largement and well-marked signs of rickets, he found. that the amount of 
haemoglobin was as low as thirty to forty per cent., the number of red cor- 
puscles about three million per cubic millimetre, the leucocytes forty to forty- 
five thousand, there were many nucleated red blood corpuscles, and some very 
large red ones (megaloblasts). The number of lymphocytes varied from 40 
to 60 per cent. In one of our cases, a girl of fourteen months, our resident 
medical officer, Dr. H. Wansborough Jones, on examination of the blood 
found 2,800,000 red corpuscles and 112,000 white corpuscles per cu. mill. 
The haemoglobin amounted to thirty per cent. There were some nucleated 
red corpuscles, and some megaloblasts and microcytes. No eosinophile cells 
were seen. 

While in a vast majority of cases the children who suffer in this way are 
under two years of age, yet occasionally we meet with older children who 
are affected in a similar manner, as in the following fatal case : 

Ancemia, Enlarged Spleen. — Thos. Arthur C, aged 5 years. Up to four months ago 
quite healthy ; no serious illness. Has lived always in Manchester. Father and mother 
healthy. Four months ago had a fall, not confined to bed, abdomen painful and swollen 
ever since, two months ago had severe epistaxis, with no known cause ; very much blanched 
ever since, feet sometimes swollen ; has had occasional pain and twitchings in left arm for 
an hour at a time, and slight twitchings of the body also. On admission, December 29, 
1881, plump, with marked pallor, a few purpuric spots on thighs and feet; superficial 
glands generally enlarged, face cedematous, no oedema of feet ; abdomen prominent in 
epigastric and hypogastric regions, liver and spleen much enlarged, heart and lungs nil. 
Urine 1020 ; no albumen. Temperature 103 P.M. June 2. — Loud systolic murmur over 
whole cardiac area, no mediastinal dulness ; heart's area increased, apex beat felt outside 
nipple line. Blood thin and watery, with some increase of white corpuscles ; spleen 
rather tender. Temperature irregular, 98 to 101 and 102 . June 13. — Constantly 
moaning; temperature still high and irregular. June 14. — Died 5 A.M., unconscious 
all night. Post-mortem. — Twelve hours after death; great pallor, some oedema of ex- 
tremities ; blood very fluid, liver unformly enlarged, pale with fine yellow points 
(hepatic vessels). No perihepatitis, spleen 5 in. by 3 in. ; smooth, firm, purple on section. 
Retroperitoneal glands very slightly enlarged ; kidneys firm and very pale. No peritonitis, 
no ascites, no staining of organs with iodine. Heart. — Left ventricle hypertrophied ; 

1 Hcematologische Stzidien, Leipsic, 1892. 

- Archivfilr Kinderheilkunde, Heft i. u. ii. 1892. 



Hodgkiris Disease 439 

right ventricle dilated, subpericardial ecchymoses, valves normal. Lungs emphysematous, 
with abundant ecchymoses on surface and in substance. No enlarged mediastinal glands ; 
brain firm, intensely anaemic, otherwise apparently healthy. No venous congestion, no 
fluid in ventricles. 

Treatment. — Iron, arsenic, and cod liver oil, especially the former, are the 
drugs most likely to be of service in anaemia, though the treatment must 
necessarily be modified according to the cause. The cachexia produced by 
syphilis must be treated by a combination of iron and mercury, with quinine 
if malaria is suspected. Care must be taken to see that the bowels are acting 
normally. 

Raw* marrow of bone, raw meat juice, orange juice, peptonised milk 
should be given. 

Hodgkin's Disease — Anaemia iymphatica. — This disease is charac- 
terised by an enlargement of various groups of lymphatic glands and also of 
the spleen ; there is progressive anaemia, and more or less intermittent fever. 
According to Gowefs statistics, 16 out of every 100 cases occur in children 
under 10 years of age. The earliest symptom which calls attention to the 
disease is enlargement of some lymphatic glands, usually the cervical, though 
the axillary or mediastinal may be early affected. 

The glands just behind, or in front of and beneath, the sterno-mastoid are 
frequently the first to be enlarged, or the group at the angle of the jaw ; the 
glands at first are firm and movable, varying in size from time to time as if 
the vessels were gorged at one time and more empty at another. With the 
glandular enlargement there is usually a marked increase in size of the 
spleen, and the child becomes weak and pallid. A prominent feature of the 
disease is the occurrence of attacks of pyrexia ; the temperature at times 
continues elevated for some days, or it may assume the intermittent type. 
Other groups of glands may become affected ; there may be an extension 
into the mediastinum, and the glands may exert pressure on the trachea or 
large veins, so that there is orthopncea, oedema, or ascites. The axillary 
and inguinal glands may also become affected. In some cases the external 
lymphatic glands may be but little affected, but the mediastinal or retro- 
peritoneal glands and the spleen may be much enlarged. The course of 
the disease is very chronic, but the prognosis is unfavourable, and sooner or 
later the child dies exhausted. At the autopsy the spleen is found enlarged 
and infiltrated with an adenoid growth, while other organs, as the lungs, 
liver, and kidneys, are also infiltrated, only in less degree. 

Diagnosis. — The diagnosis of Hodgkin's disease in an early stage is often 
extremely difficult where the patient is brought with a mass of enlarged 
glands in the neck or other part. If the glandular tumours vary in size from 
time to time, if there is intermittent pyrexia or enlarged spleen, Hodgkin's 
disease may be suspected. If the glands suppurate they are probably 
tubercular. We have frequently seen enlarged tubercular cervical and 
axillary glands mistaken for the enlarged glands of Hodgkin's disease. 
Possibly tubercular disease and Hodgkin's disease may co-exist. 

Treatment. — Arsenic and phosphorus are the medicines most likely to be 
useful, but the disease generally progresses to a fatal termination. 

leukaemia. — Leukaemia is a rare disease during childhood, but the 
possibility of its being present should be borne in mind when a pallid child 



440 Diseases of the Blood and Blood-making Organs 

with a large spleen presents itself, especially if on examination of the blood 
there is marked leucocytosis. It occurs at all ages : babies at the breast 
have been affected, and also those more advanced in years ; it cannot be 
said that anything certain is known about its etiology, though poor living, 
various depressing conditions, and malaria have been credited with producing 
it. The earliest symptom to call attention to the disease is abdominal 
distension, which is found to be due to a greatly enlarged spleen ; with this 
there is dyspepsia, perhaps abdominal tenderness, and marked anaemia. 
The disease is a chronic one, and the prognosis unfavourable. Like 
Hodgkin's disease, there may be enlargement of lymphatic glands and 
intermittent pyrexia. Later in the disease the anaemia becomes profound, 
oedema of the subcutaneous tissues takes place, and often there are 
haemorrhages. 

Two forms of leukaemia are distinguished, the mixed form in which the 
spleen and marrow of the bones are mostly involved, and the lymphatic 
variety in which the lymphatic glands are enlarged. An examination of the 
blood may solve the difficulty. 

Kanthack gives the following diagnostic points to enable the two varieties 
to be distinguished from one another and also from Hodgkin's disease : 



Hodgkin 's Disease 

Red corpuscles slightly di- 
minished. 

Hb diminished. 

Slight changes in the red 
corpuscles. 

Only moderate leucocytosis 
due to an increase of lym- 
phocytes and perhaps neu- 
trophile cells. 



Treatment. — Arsenic, 
likely drugs to be of use. 
be tried. 



Spleno-medullary Ancemia 
Red corpuscles diminished. 



Hb diminished. 

Red corpuscles vary in size 
and shape, many nucle- 
ated. 

Enormous leucocytosis, in- 
crease in large hyaline and 
eosinophile cells ; small 
relative number of lympho- 
cytes. 

phosphorus, cod liver oil and iron are the most 
Mercurial inunctions over spleen and glands may 



Lymphatic Leukcemia 
Red corpuscles diminished. 

Hb diminished. 
Rarely nucleated red cor- 
puscles. 

Enormous leucocytosis. 

Great increase of lympho- 
cytes, other kinds dimi- 
nished. 



The Hemorrhagic Diathesis 

During early life a disposition to bleed arises under many different con- 
ditions. In some cases the disposition to bleed is hereditary, in others it is 
the result of many different forms of illness. We will consider the hereditary 
variety first. 

Haemophilia.— This term is applied to a disposition to bleeding which is 
hereditary ; it affects males more often than females, but the females often 
appear to transmit this tendency to their sons. This tendency to bleed may 
only appear in one or two members of a family, the rest escaping, but those 
who thus escape may transmit the diathesis to their children. Haemophilia 
does not usually appear at the time of birth, the disposition usually first 
manifesting itself after the end of the first year of life. It is true that newly 
born children are apt to bleed from the navel or suffer from haematemesis, 
but this is the result rather of some disease than from inherited tendencies. 



Hemorrhagic Diathesis 441 

Children who exhibit this diathesis seem to exhibit it in different degrees at 
different times ; sometimes they appear to bruise on the slightest injury, 
while at other times there is hardly any tendency in this direction. Purpura 
or ' bruising ' is the most common manifestation ; slight pressure or a slight 
knock on a limb, such as might take place by the nurse catching firmly hold, 
will suffice to bring out a well-marked bruise, which is many days in fading. 
Sometimes a number of haemorrhagic spots make their appearance spon- 
taneously, and in the same way extensive subcutaneous bleedings may take 
place. A slight scratch or cut may ooze blood for some time before it stops, 
cracks or fissures in the skin of the lips may ooze in the same way. Of the 
mucous membranes perhaps the gums most often bleed — friction with a tooth 
brush may be enough to start a haemorrhage. Epistaxis is also very common, 
and may be very difficult to stop. There may be haemorrhage from the 
stomach from straining when vomiting, or blood may appear in the stools. 

Haematuria also takes place at times. Haematomas of the scalp are liable 
to follow slight falls, or injuries and bleedings of considerable amount may 
take place in the muscles and other deeply situated structures. Bleedings 
may take place into the joints, especially the knees. It may be the result ot 
injury, but in some cases this does not appear to be the case. The joints 
appear swollen and tender, and contain fluid — the fluid gradually disappears 
with rest ; but if repeated bleedings occur much thickening of the synovial 
membrane with overstretching of the ligaments and nodular swellings, 
resulting in distortion and more or less permanent crippling of the joint, may 
result. A joint into which haemorrhage has once taken place is apparently 
likely to suffer again. We have seen patients lamed for life in this way. 

We have also met with a case in which, in addition to haemorrhage into 
joints on several occasions, bleeding took place beneath the palmar fascia, 
causing great pain, and a somewhat alarming appearance of the hand. The 
blood was, however, slowly absorbed, and no serious ill result followed. The 
history of the patient is as follows : 

Hemophilia, Effusion in Knee Joint. — L. , a boy of 14, was first seen in September 
1890, with Dr. Massiah. There was no history of haemophilia in the family. At 
Christmas 1889 he sprained his left knee, and it at once filled with blood, and has never 
been well for any length of time since. The left leg is smaller than the right, and is said 
to have always been so. When seen in September the left knee was enormously distended 
with fluid blood, and was a good deal hotter than the other. His brother, who was seen 
at the same time, had numerous bruises, and one ankle contained fluid blood, which was 
becoming absorbed and giving rise to discoloration of the adjoining parts. On examining 
the knee thirteen days later it much resembled a joint the subject of chronic rheumatic 
arthritis ; there was thickening of bone and crackling of the joint, with occasional ' locking.' 
The limb could not be fully extended, and there was ^ inch shortening. In April 1892 he 
was seen again ; the knee was again swollen after an injury, though not to the extent of 
the former attack. 

Perhaps the most serious complication of all is a cerebral haemorrhage. 
This may be the result of a blow or a knock, or it may apparently occur 
spontaneously. Thus a girl of 3f years, who had had from time to time 
bruise marks on her skin, suddenly developed symptoms of paralysis of the 
respiratory muscles, and she died asphyxiated in three or four days. At the 
post-mortem a haemorrhage into the medulla was found. (See case under 
Medullary Hemorrhage, p. 511.) 



44 2 Diseases of the Blood and Blood-making Organs 

The prognosis in all these cases of haemophilia is necessarily uncertain. 
They arc carried off in many cases by intercurrent disease, to which they fali 
an easy prey, or as the result of some accident. It is certain that some 
reach adult life, as examples of this condition are not uncommon among 
adults. 

The diagnosis is not difficult in a well-marked case, but there may often 
be a doubt as to whether the disease is hereditary or whether it has super- 
vened on some form of disease, but in the hereditary form the history of 
bleeders in the family will necessarily be of help. 

Very little is known for certain about the pathology of these cases. It 
has been supposed that there is some congenital affection of the arteries or 
the capillary vessels, which allows the blood to easily ooze through their 
walls, but this has not been substantiated. We must be content for the 
present to confess our ignorance. 

No children require so much care or are greater causes for anxiety than 
habitual bleeders. No operation, however slight, can be permitted in these 
cases. Gum-lancing, excision of tonsils, drawing teeth, opening abscesses, 
must be avoided. They must be carefully watched and guarded in every 
relation of life. When bleeding is going on turpentine, hazeline, ergot, and 
gallic acid are the most likely drugs to be of service. Tr. ferri perchlor. may 
be applied locally. When bleeding has taken place into a joint, the child 
should be kept in bed with the affected joint fixed in a splint and cooling 
lotions applied. After a week of rest, if no recurrence of the bleeding takes 
place, very gentle movement and rubbing should be employed to prevent 
stiffness and favour absorption of the blood as perfectly as possible. All 
violent exercises must be avoided by these children ; they are, in consequence, 
a source of constant anxiety to their friends. 

Purpura simplex, Purpura haemorrhag-ica.- — These terms are applied 
to conditions in which the hsemorrhagic diathesis has been acquired, that is, is 
not hereditary. The name P. simplex is applied when the bleeding is sub- 
cutaneous only, that of P. haemorrhagica when the bleeding takes place from 
various sources besides the skin, such as kidneys, &c. 

Purpura haemorrhagica occurs under a number of different conditions. 
Thus it occurs (1) in malignant smallpox and measles, in typhus, occasionally in 
scarlet fever, in acute ileo-colitis, and especially in diphtheria — -in these cases 
it is no doubt due to the presence of albumoses in the blood ; (2) in various 
anaemic conditions, especially towards the later stages, when the anaemia is 
severe, such as scurvy, pernicious anaemia, Hodgkin's disease, rickets and 
syphilis ; (3) and we have it following attacks of gastric catarrh, diarrhoea, 
croupous pneumonia, whooping cough, in rheumatism and also in meningitis. 

It occurs at times without being associated, as far as can be made out, 
with other diseases ; but it may be doubted if it is ever an independent disease. 
In most cases, at any rate, some other disease precedes it, and it seems rather 
to occur as the result of changes effected in the blood by the pre-existing 
disease. 

Purpura sometimes makes its appearance as a mild affection, at other 
times it is acute and quickly fatal. Thus a child may present itself with 
large and extensive ecchymoses on the limbs or trunk, but it is not in the least 
ill, and the subcutaneous bleedings disappear in a few weeks or less. Or 



Purpura HcBinorrJiagica 443 

perhaps a child is seized in the midst of apparent health with ecchymoses 
and severe haemorrhages from the kidneys or from the alimentary canal ; 
there is delirium, and then coma and death in a few days. Sometimes purpura 
accompanies a type of disease which resembles scurvy more than anything 
else, and yet there has been no deprivation of fresh food or hardship of any 
sort. As an example of this we may relate the following case : 

Purpura Hemorrhagica. — Guy F., aged six years. Was always a fairly healthy boy 
till August 1889, when he had a severe attack of diarrhoea, with collapse, at the seaside. 
He never completely recovered himself, being pale and weak. At the end of the following 
January he suffered from spongy gums, occasional vomiting of dark blood, and frequent 
bruise marks on his body. He continued much in the same state for the next month, 
when (February 14) he tripped and fell, striking his head against the edge of a table. A 
haematoma of the scalp quickly formed on the right side of his forehead ; during the same 
night the fingers of the left hand twitched continuously, and the grasp on that side was 
feeble. Next day the grasp of his left hand was very weak, and there was some difficulty in 
flexion and extension of the wrist. Four weeks after the accident the haematoma and 
bruising had nearly disappeared, and power had mostly returned in the left hand. He, 
however, continued to go downhill, there was pain in the stomach and frequent vomiting, 
oozing of blood from the nose, and purpuric spots appearing on the trunk and limbs. A 
loud, rough bruit was heard over the whole heart area, he became more and more anaemic, 
and there was marked wasting. He was unconscious for 20 hours before death, which 
occurred at the end of March. Post-mortem.— -Excess of clear fluid in the serous cavities ; 
punctiform bleedings on surface of heart and lungs ; no valvular lesion ; muscle of heart 
pale, left ventricle dilated. Stomach much dilated ; walls of stomach and also of intes- 
tines very thin. Spleen enlarged and soft. Extensive subarachnoid haemorrhage over 
surface of the brain ; some red fluid between dura and arachnoid. On the right ascending 
frontal convolution is a haemorrhage, circular in shape, involving the width of the convo- 
lution, extending an inch into brain substance. The bleeding had involved the hand centre. 

The ecchymoses which occur vary much in size and number ; in rare cases 
the greater part of an arm or thigh is of a dark purple colour from haemor- 
rhage beneath the cutis. In other cases the purpuric patches vary in 
size from mere points like haemorrhagic flea-bites thickly scattered over 
the skin to patches the size of the palm of one's hand. In erythema nodosum 
the nodes, which are first of a rosy tint, become in a day or two purple from 
capillary haemorrhage. In rare cases patches of subcutaneous haemorrhage 
become gangrenous ; Sangster has recorded such a case. A girl of 5 years 
had several purpuric patches on the extremities and cheeks ; one of these 
on the arm ended in gangrene, recovery eventually taking place. Steffen has 
collected several more cases, in which multiple skin gangrene occurred after 
purpura ; the cases proved fatal. 

In a number of cases haemorrhage occurs either on the surface or into the 
substance of the brain. We have already referred to two such cases coming 
under our notice, one in which there was medullary haemorrhage, and the 
other in which a small bleeding occurred in the Rolandic area. Grosz (loc. 
cit.) records a case where there was a haemorrhage the size of a nut in the 
substance of the right lobe of the cerebellum, and also beneath the pia mater. 1 
Steffen has collected four fatal cases in which meningeal haemorrhage or 
haemorrhage into the brain substance was foundry/ mortem. In some cases 

1 See Grosz, Ueber Purpura im Kindersalter : Archiv fur Kinderheilk. Heft i. u. ii. 
1894. 



444 Diseases of the lUood and Blood-making Organs 

there has been evidence of brain haemorrhage, in which recovery has taken 
place. Haemorrhage has also been found in the substance of the spinal 
cord. 

Steffen reports cases in which a myocarditis occurred in the course of pur- 
pura, leading to dilatation of the left ventricle ; and a consequent inefficiency 
of the mitral valves. In such cases a mitral murmur will be heard during 
life. (See case, p. 443.) Haematemesis is not uncommon. Indeed, vomiting 
is frequent, the vomited matter being streaked with blood, probably from 
punctiform bleedings taking place in the stomach. Blood in the stools also 
occurs in these cases, and punctiform bleedings are frequently found post 
mortem. Haematuria is a frequent symptom ; in some cases there is 
albuminuria and no blood present. 

The association of purpura with rheumatism is an interesting one. Schon- 
lein gave the name of Peliosis rheumatica to a form of purpura in which the 
joints were affected. Probably Steffen is right in altogether dropping the name, 
inasmuch as the so-called Peliosis rheumatica is purpura in which there has 
been bleeding into the joints or the muscles or tissues around the joints. In 
true rheumatism purpura does occasionally occur, and as is well known 
Erythema nodosum occurs in association with rheumatism. 

As a rule an attack of purpura is feverless, but in some cases there is 
moderate fever, especially before the appearance of a crop of petechias. In 
the acute cases, such as have been described by Henoch, Pye-Smith, and 
others, in which there is vomi ting, haematemesis, haematuria, petechias, delirium 
and coma, there may be a high temperature. 

An examination of the blood during an attack shows a diminution of the 
haemogloblin and of the red corpuscles. The leucocytes may at first be in 
slight excess, but they also diminish in number. Micro-organisms have been 
found, but as yet bacteriology has shed but little light on the pathology of 
this disease. Experimentally, it has been shown that the presence of 
peptones and albumoses in the blood, give rise to haemorrhages and many of 
the symptoms of purpura. 

Concerning the prognosis in purpura little can be said. Purpuric small- 
pox is well-nigh always fatal, and purpura occurring during the course of 
diphtheria is an extremely bad omen. In malignant scarlet fever and also in 
malignant measles the rash is at times said to be purpuric. We -have never 
seen such cases, but on several occasions we have seen the rash in both 
diseases assume a purpuric appearance, and recovery take place without a 
bad symptom. In some forms of anaemia Avith wasting, the appearance of 
purpura marks the beginning of the end. Purpura simplex is always of less 
grave import than those cases in which haemorrhages occur from internal 
organs. 

The treatme7it of purpura is the treatment of haemorrhage generally. 
Among the most valuable haemostatics are turpentine (TT|v-xx), ex. hamamelis 
liq. (n\v-rfixx), ex. ergotae liq. ("n\v-lT\xx), ergotine by subcutaneous injec- 
tion, gallic acid (gr. v-gr. x), and acetate of lead (gr. |-gr. i). 

Diseases of the Retro -peritoneal Glands. — -There are a considerable 
number of lymphatic glands situated behind the peritoneum, at the back of 
the abdomen and in the pelvis. They are most numerous lying along the 
vena cava inferior and aorta and their branches. These glands may become 



Retro-peritoneal Glands 445 

enlarged and caseous in tubercular disease, or may be the starting point of a 
lymphadenoma or abscess. When caseous, they are so in association with 
mesenteric disease ; in one case under our care the caseous glands surround- 
ing the vena cava completely compressed the latter, giving rise to oedema of 
the lower limbs and enlarged veins on the surface of the abdomen. In 
another case a lymphadenomatous tumour exactly simulating an enlarged 
spleen, which had commenced in some retro-peritoneal glands, was first noted 
in the left hypochondriac region. It grew to an immense size, occupying 
nearly half the abdomen. Some of the more obscure forms of abdominal and 
pelvic abscesses appear to originate in these glands. 



446 Syphilis 



CHAPTER XXI 

SYPHILIS 

INFANTS and children may suffer from syphilis acquired in various 
ways after birth, or they may be the subjects of hereditary syphilis, the 
virus in this case being received from one or both parents during intra- 
uterine life. The infant may be inoculated with the syphilitic germ at the 
time of birth. 

Acquired Syphilis. — Can a healthy infant be syphilised by means of 
the milk of a wet-nurse ? This is an important question, and one which is 
often asked by parents before a wet-nurse is employed ; there is no evi- 
dence that we know of to show that it can, and there is a strong probability 
that even if the virus was present in the milk it would not inoculate the infant 
unless introduced directly into the blood. That the infant can be inoculated 
if it have an abrasion on the lips and it draws blood from a sore nipple of a 
nurse suffering from secondary syphilis is certain, and it may, of course, be 
inoculated by the discharges from the genitals of the nurse conveyed to it 
on the nurse's hands. It need hardly be said that in selecting a wet-nurse 
the most scrupulous care should be exercised in ascertaining that the would- 
be nurse is not suffering from any specific disease ; a careful inquiry must be 
made as to her health and the health of any children she may have had, 
especially with regard to any symptoms of syphilis. 

Children of various ages may be seen in dispensary practice suffering 
from chancres on the lips and genitals, who have been inoculated from their 
parents or others having specific sores, the virus being perhaps conveyed on 
the fingers. It is important to bear in mind that not only are the discharges 
from a primary sore liable to inoculate, .but the discharges from various 
secondary lesions both in acquired and hereditary syphilis may also infect. 
Thus infants suffering from coryza or specific ulcerations about the mouth 
may inoculate the breast of a healthy wet-nurse, though they apparently 
never do that of their mother. No syphilitic infant should be wet-nursed by 
any one except its mother. It must, however, be stated that while Colles 
relates instances of syphilitic infants inoculating their foster-mothers, many 
recent writers doubt the infectiousness of hereditary syphilis, and in many 
foundling hospitals on the' Continent wet-nurses are allowed to suckle 
syphilitic infants apparently without harm resulting. 1 

The symptoms of acquired syphilis in children are the same as those seen 
in adults. There is a chancre followed by sore throat and a roseolous rash. 

1 See R. W. Parker, ' Is Inherited Syphilis Contagious?' Edin. Med. Jour., June 1896. 



Acquired Syphilis — Hereditary Syphilis 447 

But as Coutts has well pointed out, the rash is apt to be scanty and evanescent, 
and may be easily overlooked, while subsequently there is a marked tendency 
to the growth of condylomata. 

Syphilis has undoubtedly been on rare occasions inoculated by means of 
vaccination : abundant evidence of this exists in some epidemics of syphilis 
which have occurred, though such an accident is exceedingly rare. It may 
often happen that when vaccination is performed it is followed in a few days 
or weeks by symptoms of secondary syphilis, such as a roseolous rash, coryza, 
&c, but in the absence of a primary sore at the seat of vaccination these 
syphilitic manifestations cannot be accepted as evidence of vaccino-syphilis, 
and evidence may most probably be obtained of syphilis in the parents 
or in some of the brothers or sisters. As the first symptoms of hereditary 
syphilis most frequently make their appearance at from six weeks to three 
months after birth, and as this is the usual time for vaccination, it is highly 
probable that vaccination and the secondaries will often exist together and 
yet have no connection. If syphilis has been inoculated by vaccination, a 
month or six weeks later — during which time perhaps the vesicles have im- 
perfectly healed — an induration makes its appearance at the seat of one or 
more of the vesicles, or there is an ulcer with an indurated base which has 
the characters of a hard chancre ; this remains indolent, crusts over, and is 
followed in the course of a few weeks more by a specific eruption and other 
specific phenomena. In any case where vaccino-syphilis has taken place a 
well-marked scar is left at the seat of the puncture where the hard chancre 
has formed. 

It is important to remember when investigating any case of supposed 
vaccino-syphilis that an interval of a month or six weeks elapses between 
vaccination and the formation of a chancre at the seat of inoculation 
(Hutchinson), and the diagnosis of syphilis cannot be accepted unless this is 
the case. 

Hereditary Syphilis. — In hereditary syphilis the foetus receives the 
poison at some period during intra-uterine life, and may be born with the 
evidence of syphilis on it, or it is born healthy, the specific symptoms making 
their appearance within a few weeks or months of birth. In these cases, 
unlike acquired syphilis, there is no primary sore. The part played by the 
father in transmitting syphilis to his progeny does not admit of a doubt : the 
more recently he has suffered, the more likely is he to transmit it in a severe 
form, though for many years he is liable to beget children who suffer from 
hereditary syphilis. The most usual way in which he transmits it is by 
means of the spermatozoa at the time of fertilisation of the ovum ; or during 
the intra-uterine life of the foetus the mother may become infected by the 
husband, and she may infect the foetus through the placental circulation, though 
this appears to be rare during the later months of intra-uterine life. The 
mother may transmit the disease to the ovum or the foetus in utero, but this, 
as just stated, is rare after the seventh month of foetal life ; or she may infect 
it during the act of birth. The mother, on the other hand, may apparently- 
be infected from the foetus, though often she appears to escape ; that is, a 
syphilitic father infects the ovum, the child is born and suffers from syphilis, 
the mother apparently escaping ; but the escape of the mother is more 
apparent than real, inasmuch as such women appear to be insusceptible to 



44 8 Syphilis 

syphilis, and there is reason to believe that they do not escape, though the 
attack must certainly be slight. This was very definitely laid down by Colles, 
and is generally known as his law. He states that he had never known a 
syphilitic infant, although suffering from ulcerated mouth, infect the breast of 
its mother, whereas very few instances had occurred to his knowledge of a 
hired wet-nurse escaping under the same circumstances. Recent writers, 
namely, Parker, Coutts, Ogilvie, have brought forth evidence to show that 
at any rate Colles' law is not universally true. They assert that inherited 
syphilis is but slightly or not at all contagious, that wet-nurses are not 
affected, and if this is true, it will explain how the mother escapes without 
assuming that she is protected by a previous attack. A very few cases have 
been recorded in which a syphilitic infant has apparently infected its mother. 
It would certainly seem that while acquired syphilis in infants is virulently 
contagious, inherited syphilis is but slightly so. 

The following is a summary of the modes of infection in hereditary 
syphilis. 

i. The ovum may be infected by the spermatozoa of the father (paternal 
heredity). 

2. The ovum may be infected by the mother (maternal heredity). 

3. The ovum may be infected by both (mixed heredity). 

4. The foetus may become infected by the mother becoming infected 
during pregnancy. 

5. The mother may become infected by the foetus. (Syphilis by concep- 
tion.) 

The mixed infection is the most serious, and the more recently the parents 
have suffered from syphilis, the more severely will the infant suffer. In four- 
fifths of the fatal cases of hereditary syphilis, the infants have been born 
within three years of the parents being syphilised (Fournier). Syphilis derived 
from the mother alone is more serious than syphilis from the father alone. 

Effects of the Poison on the Foetus. — The mother may miscarry at any time 
during foetal life, a result due to disease of the foetus or placenta ; this is 
especially likely to happen if the father and mother are suffering from the 
disease in an active form. The exact nature of the lesions is uncertain : 
the placenta and internal organs, as the liver, lungs, &c, have been found 
diseased. The infant may be born at term, but dead, or may survive its 
birth but a short time ; in the latter case it is puny, shrivelled, with blue 
extremities and a feeble hoarse cry. It may suffer from various skin erup- 
tions, the most common (in the newly born) being pemphigus ; various 
internal lesions may be found, such as interstitial hepatitis, and there may be 
gummata, perhaps breaking down, in the thymus, heart, or lungs. It may 
exhibit a tendency to bleed (see p. 34). 

Symptoms a?id Course. — The first definite symptoms usually make their 
appearance during the second month of life. These are often preceded by 
more ill-defined symptoms, such as restlessness, fever, peevishness, diarrhoea, 
and dyspepsia. The infant suffers from what appears to the friends to be a 
cold in the head : the nasal passages are obstructed by excessive secretion 
and the infant ' snuffles ' during inspiration ; in the more severe cases the 
breast is taken with difficulty, as respiration is impeded during sucking on 
account of the nose being blocked, and the infant has to stop to breathe 



Hereditary Syphilis 449 

through its mouth. The coryza is followed by a characteristic rash, which 
usually consists of an erythema or erythematous patches of various sizes, 
the favourite places being about the anus, genitals, thighs, and forehead. 
These patches or plaques have sharp cut edges, are dull red in colour and 
shiny. Instead of an erythema the rash may be papular. When the erup- 
tion appears first it is a bright red, the^ vividness fades in a day or two, and 
the skin desquamates, and becomes of a dull red or coppery hue. As the 
disease progresses the secretion oozing from the nose dries up and forms 
scabs, the entrance to the nostrils becomes sore, and perhaps a sanguineous 
purulent secretion escapes from time to time. The upper lip may become 
excoriated and scabbed over. The corners of the mouth, which are con- 
stantly moist from the excess of saliva, become raw and perhaps ulcerated, and 
fissures and scabs may form which heal but slowly, leaving radiating scars 
(figs. 89, 90). 




Fig. 89. — Fissures around the Mouth in a case of Congenital Syphilis. 
The whole appearance of the face is characteristic. 

At this time a multiple epiphysitis frequently occurs. The infant cries 
when it is handled, and the ends of some of the bones, especially the lower end 
of the humeri, the wrists and ankles, are found swollen and tender (see fig. 93). 

The mucous membrane of the larynx may be affected, becoming swollen 
and perhaps ulcerated, and the child in consequence has a hoarse cry ; there 
may be marked anaemia and wasting, so that the child emaciates and is 
reduced almost to a skeleton. 

Infants occasionally die at this period, apparently from the intensity of 
the poison. This seems to have been so in the following case — our post- 
mortem notes are as follows (the child was not seen during life by any medical 
man) : 

The mother states that the infant, which was seven weeks old, ' snuffled ' a week before 
its death, and three days before a reddish rash appeared on the buttocks and around the 

G G 



450 



Syphilis 



mouth. It was found dead in its cot. At the autopsy the infant was fairly well nourished, 
there was a purulent discharge issuing from its nose, the skin around the mouth and nose 
was excoriated, apparently from the nasal secretion, and there were some excoriations and 
redness around the anus. The whole of the mucous membrane of the nose was in a foul, 
almost sloughy condition, the surface being dark-coloured and covered with muco-pus. 
On one tonsil there was a deep ulcer ; there was no laryngitis ; all the other organs in the 
body were healthy. 

While in the more severe forms the infant is the colour of cafe au lait, 
wizened and wasted, other infants may be seen who are plump and ruddy, 
yet who are undoubtedly syphilitic, and who subsequently develop a typical 
rash. In some who suffer later from syphilis no history can be obtained of 




Fig. 90. — Congenital Syphilis, showing flattening of bridge of nose, scars around 
mouth, and keratitis. 



coryza or rash, and we are driven to the conclusion that the secondaries are 
sometimes so slight as not to attract the attention of the friends, and may 
even deceive the medical practitioner. The mortality of syphilitic babies is 
high ; not only is the effect of the poison depressing, but the blood seems to 
be profoundly altered, the digestive organs are interfered with, and the infant 
wastes and dies. ' Congenital syphilis] ' mal-nntritio?i ' is written on the 
death certificate of many syphilitic babies. 

On the other hand those who suffer in a less severe form and come under 
treatment early rapidly improve, gain flesh, and for a time at least all sym- 
ptoms disappear. While such cases may apparently be entirely cured, yet 
like the secondaries which occur in adults, the symptoms are very apt to re- 
appear, especially during the second and third years. This relapsed syphilis 
may make its appearance in children in whom the symptoms following birth 



Hereditary Syphilis 



45 1 



are slight, and consequently what is really relapsed syphilis is very apt to be 
mistaken for acquired syphilis. This recurrence usually takes the form of 
condylomata or ulcerations about the anus or tongue, and chronic fissures 
about the corners of the mouth and nose ; various rashes may also be present. 

During the next few years the child may remain fairly well, but on the 
approach of puberty symptoms which correspond to the tertiaries of adults 
may make their appearance. Children at this period often bear the marks 
of past lesions, and if seen for the first time there may be no difficulty in 
recognising them as subjects of congenital syphilis, as their flattened noses 
and the linear scars at the angles of the mouth, and typical pegged teeth, 
give them a characteristic appearance (fig. 90). They are apt at this time to 
suffer from periostitis, caries of bone, chronic ulcerations, ulcers of the 
mucous membrane covering the hard palate, which may involve the bone ; 
ulceration and destruction of the 
soft palate ; various affections of 
the eye, as iritis, keratitis, choroi- 
ditis ; various skin diseases, as 
ecthyma, rupia, &c. ; gummata in 
the superficial structures, and also 
in the liver and other internal 
organs. Deafness and partial de- 
mentia may be present, the latter 
accompanied by syphilitic arteritis 
of the brain. In the worst cases 
the child may suffer for years from 
disease of one or other of the 
bones (figs. 91, 92). 

Having sketched the course of 
the disease, we may now proceed 
to describe some of the phenomena 
presented by congenital . syphilis 
more in detail. 

Skin. — Pemphigus is one of the 
most characteristic of the syphilitic 
rashes, and when present at birth 
may be taken as certain evidence 
of hereditary syphilis. The seat of the blebs in syphilitic pemphigus is the 
palms of the hands and soles of the feet, but they may be present also on the 
extremities and trunk ; their contents are purulent or sanguineous ; they may 
be succeeded by deep ulcers. According to Roger non-specific pemphigus is 
rare before three years of age and most common after six years ; the blebs 
are rarely numerous, do not occur on the palms of the hands or soles of the 
feet, and contain serum rather than blood or pus. The prognosis is bad in 
syphilitic pemphigus if the infant is born with the rash ; as a rule, the later 
it appears, the better is the prognosis. The commonest rash in hereditary 
syphilis is a roseola, which may take the form of a bright-red diffuse rash 
with a sharply defined edge surrounding the genitals, with perhaps patches 
of similar redness about the body or face, or there may be roseolous spots 
or maculae about the body, with a more .diffuse rash on the soles of the feet. 




Fig. 91. — Complete Destruction of the Nose, 
Upper Lip, and part of the Jaw in Congenital 
Syphilis, in a boy aged 10 years. 



452. 



Syphilis 



The eruption is at first a vivid bright red ; in a few days it fades, becom- 
ing more of the tint of lean ham ; then the affected part desquamates, 
leaving the skin smooth, shiny, and dry. The rash may be visible for weeks, 
assuming in its later stages a coppery colour. Instead of the roseola, the 
rash may consist of papules of a bright red colour, which are confluent 
about the genitals and buttocks, but scattered irregularly over the body. The 
rashes most likely to be confounded with a syphilitic roseola are those 

so commonly present about the geni- 
tals, especially those produced in in 
fants with diarrhoea by the irritation 
of fasces and wet napkins. The 
difficulty of diagnosis is only likely 
to arise in the absence of a charac- 
teristic rash in other parts of the 
body, or of ccryza. It is needless to 
say that a red rash with excoriations 
and signs of irritation about the 
anus and genitals may occur in both 
syphilitic and non-syphilitic children, 
and no rash in this situation should 
be regarded as specific without con- 
firmatory evidence elsewhere. Some- 
times the 'napkin-rash, 5 which is 
present about the genitals and folds of 
the knee, takes on a syphilitic aspect ; 
there are small, shallow, kidney- 
shaped ulcers with raised mucoid- 
looking edges. Psoriasis, or scaly 
rashes ) vesicles, pustules, zxi&ecthyma, 
may occur in syphilis, in infancy 
Simple psoriasis rarely occurs before 
the third or fourth year, while syphi- 
litic scaly rashes are not uncommon 
in early childhood, on the plantar 
and palmar surfaces, and on the 
face. Pustules followed by deep 
ulceration are not rare in cachectic 
children apart from the effects of 
syphilis ; thus occasionally in chicken- 
pox the vesicles are succeeded by 
pustules or bullae and a deep ulcera- 
tion is produced. In making a diagnosis several points must be borne in 
mind : syphilitic rashes mostly affect the genitals, palmar, and plantar 
surfaces, and face ; they are usually bright red at first, then dull red and 
more or less of a coppery hue ; they are followed by free desquamation, and 
they cause no itching. Different varieties may be associated together. 

Mucous patches and coiidylomata when present are of great diagnostic 
value ; they may occur at all ages, but are especially common in relapses 
in children two or three years old. Their common seat is around or by 




Fig. 92. — Congenital Syphilis. Disease of bones 
of upper and lower extremities. 



Hereditary Syphilis 453 

the side of the anus, vulva, fold of the groin, corners of the mouth, entrance 
to the nares — less commonly the folds of the neck. They form where there 
is some irritation, where a surface of skin is fretted by some discharge and 
kept constantly moist. Mucous patches may be present on the side of the 
tongue and soft palate. We must not forget, however, that acquired syphilis 
is not uncommon in children, and cases seen with condylomata may be 
suffering from the acquired form and not from hereditary syphilis. 

Corysa is perhaps the most constant symptom present. The mucous 
membrane of the nose is swollen and congested, and respiration is carried on 
with difficulty on account of the obstruction. The infant is very restless at 
night, waking at short intervals to get its breath. Later on a purulent dis- 
charge tinged with blood makes its appearance, which frets and irritates 
the skin in the neighbourhood, and ulcers and crusts form along the upper 
lip and side of the nose. Caries of the nasal bones may take place ; there 
may be a discharge of pus, which makes its appearance down the nose and 
at the corners of the eyes. 

Lesions of internal organs. — Parrot has pointed out that an ulceration 
due to syphilis occurs occasionally near the median line inside the lower 
lip ; serpiginous ulcers occur on the tongue, inside the lips, near the corners 
of the mouth, on the gums and soft palate ; they are mostly shallow, with 
a red and shiny base, surrounded by a raised, whitish, irregular border. 
Condylomata on the tongue are much commoner than any form of ulcera- 
tion. Deeply cut ulcers make their appearance on the hard palate in 
tertiary syphilis, the bone is quickly affected, and a communication with the 
nasal cavity established. A deep ulcer may form on the soft palate, and 
shortly a sharply cut hole be seen right through the velum palati. Laryngitis, 
mucous tubercles, and ulcerations along the edge and at the base of the 
epiglottis, occur, but specific lesions of the larynx are less common in 
children than in adults. Specific lesions of the lung's are not common, 
though syphilitic infants frequently die of broncho-pneumonia. In the 
lung-s of infants born dead, or dying soon after birth, gummata and fibroid 
indurations may be found, and a form of chronic pneumonia which has been 
described as white hepatisation by Virchow. Patches of white hepatisation 
may sometimes be found scattered through the unexpanded lungs of infants 
born dead, and the mediastinal glands may also be enlarged and infiltrated 
in a similar way. The gummata are most often seen on the surface of the 
lung and are apt to soften in the centre (Parrot). The liver of newly born 
infants may be enlarged from the effects of interstitial hepatitis. Gummata of 
the liver are occasionally found in infants and older children, but they are 
comparatively rare. Depressed scars, the remains of gummata, may also be 
seen. (See pages 187 and 188.) 

The spleen is frequently enlarged and indurated, especially where 
cachexia is a marked symptom, as pointed out many years ago by Gee. It 
is generally simply indurated, but gummata have been found. Dr. G. F. 
Still records a case of a boy of eleven years, in whose spleen were found 
gummata from \ in. to f in. in size, and another case in a boy of six years, 
the spleen was found enlarged with many yellow fibrous masses, varying in 
size from a pin's head to a horse-bean. 1 

1 Path. Soc. Trans., 1897. 



454 Syphilis 

Lesions of the brain may also occur especially during the first or second 
year. The infant suffers from eclampsia, most marked on one side ; the 
convulsions perhaps begin in one hand and then become general, they are 
frequent rather than severe. Later the arm gradually becomes paralysed 
and spastic ; later still the leg of the same side is affected in the same way. 
The limbs of the other side also suffer, and the infant gradually passes into a 
condition of dementia. At the post-mortem syphilitic endarteritis and 
softening are found. Chronic hydrocephalus may also occur in syphilitic 
children. Dementia and general paresis may come on in the course of 
syphilis about puberty ; gummata of the brain are rare, only a few cases are 
recorded (Henoch, Barlow). Gummata have in rare instances been found in 
the kidney, testes, and glands (Fournier). 

Syphilitic disease of the bones may occur both early and late in the dis- 
ease. Caries of the nasal bones may follow the coryza, leading to the falling 
in of the nose which is so common in syphilitic children ; or the bones may 
be completely destroyed. During the tertiary period caries of the hard 
palate and turbinated bones, as well as of the long bones, more especially 
the tibia, may occur. In the latter bone caries may follow periosteal nodes ; 
or thickening of the bones may be met with. Apart from caries a peculiar 
inflammation termed syphilitic epiphysitis is apt to occur near the epiphyses 
in the long bones in infants, especially at the lower ends of the humerus, 
femur, radius and tibia. The mother notices that the infant does not move 
an arm or leg so freely as the other, and it screams as if in acute pain if the 
limb is handled or moved suddenly. An examination of the end of the 
humerus, if the arm is affected, may show it to be swollen and tender, and 
the limb hangs useless, so that the term ' pseudo-paralysis ' has been applied. 
(See fig. 93.) The shafts of several of the long bones perhaps show an 
enlargement where they join the epiphyses, and sometimes a slight 
effusion is present in the joint. More rarely the phalanges of the fingers 
are also swollen. The nature of this lesion has been studied with great care 
by Wegner, Parrot, Taylor, and Kassowitz. Separation of the epiphysis 
from the shaft and the formation of an abscess may take place, though in 
this country the latter accident is rare. Lesions in the cranial bones have 
been described by Wegner ; he found gummatous periostitis of the dura 
mater beneath the parietal bone, a possibility to be borne in mind when 
epileptiform attacks occur in syphilitic children. The natiform skull belongs 
to rickets rather than syphilis ; a hypertrophic condition of the bones of the 
forearm and leg, giving rise to a marked enlargement of the shaft of the 
bones, is not uncommon (see fig. 92). 

Chronic synovitis of the knees, wrists, &c. is apt to occur in older 
children (see Diseases of Joints). 

The teeth of the second or permanent set are often misshapen and 
peculiar. The most characteristic changes are seen in the central incisors 
of the upper jaw ; they are more or less dwarfed, peg-shaped — i.e. they taper 
inferiorly — slant towards each other, and have a central notch in their cutting 
edge ; the other incisors may be more or less dwarfed and notched. 

Affections of the eyes are most common about puberty, the commonest 
being interstitial keratitis, iritis, and choroiditis. The two former usually 
occur together, though they may occur singly. The first symptom noticed 



Hereditary Syphilis 



455 



is watering and irritation of the corneal conjunctiva, then a steamy appear- 
ance or cloudiness of a portion of the cornea : this is followed by the forma- 
tion of minute blood-vessels on the surface of the cornea, giving the steamy 
patches in some cases a reddish or salmon-coloured tinge. These patches 
loin the sclerotic, are generally symmetrical, and are apt to relapse. Dis- 
seminated choroiditis may occur : in such cases small patches of atrophy of 
the choroid, of a white or grey colour, are generally seen scattered about 
the fundus of both eyes ; pigmentation is frequently present ; there is often 
the remains of a past retinitis and neuritis. 

Ears. — Gradually increasing deafness, which is often very intractable to 
treatment and depends on labyrinthine mischief, is common in congenital 
syphilis. It usually appears at about the same age as interstitial keratitis, 
i.e. from the seventh to the fifteenth year, but occasionally begins much 





Fig. 93. — Swelling of lower ends of Tibia and Fibula, and also of the Radius and Ulna, from a 
syphilitic infant of four months old. The swelling lies at and above the line of junction 
between the epiphyses and shafts. (Compare with Rickety Enlargement, p. 201.) 



later. Complete deafness frequently results from this affection. The three 
lesions of the teeth, the cornea, and the ear are known sometimes as 
' Hutchinson's triad ' of symptoms, and may be looked upcn as quite patho- 
gnomonic. Middle ear disease is also sometimes caused by congenital syphilis. 
Diag?iosis. — This is often difficult and sometimes remains uncertain. In 
the infant care must be taken not to mistake, as students are very apt to do, 
an erythema about the genitals, which has its origin in the irritation caused by 
fouled napkins, for a specific rash, or, on the other hand, hastily to assume 
that an infant is not syphilitic because there is a certain amount of excoria- 
tion and rawness about the anus caused by the fretting of the wet napkins. 
No rash can be taken as characteristic which is not present in other places 
as well as about the genitals, out of reach of the irritating effect of the 
urine or faeces. Coryza in an infant a few weeks old is exceedingly suspicious, 
"especially in the absence of signs of catarrh of the bronchial tubes or larynx, 



45^ Syphilis 

and if it remains chronic is probably syphilitic, even though a rash may never 
be present. Infants may, however, suffer from acute coryza without being 
syphilitic. A purulent discharge and caries of the nasal bones is usually syphili- 
tic. Tenderness and swelling of the epiphyses of the long bones in an infant are 
strong evidences of syphilis ; we attach no importance to cranio-tabes. or 
bosses on the cranial bones, or the natiform skull, as they may be undoubt- 
edly present in rickets and perhaps other conditions. Syphilitic epiphysitis 
can hardly be mistaken for the enlargement of the epiphyses present in 
rickets. In syphilis the swelling is situated between the epiphysial line and 
the shaft (see fig. 93), while in rickets the swelling involves the epiphysis 
itself (see fig. 30). Syphilitic thickening occurs in infants of six weeks to 
three months old, while the rickety enlargement is rarely seen before six 
months, and more commonly at a year or eighteen months of age. 

Marasmus, anaemia with enlarged spleen, and eclampsia may all occur in 
infantile syphilis, but in the absence of other symptoms we must be very 
cautious in accepting them as evidence of syphilis. 

Treatment. — In all cases where the parents are known to have suffered 
from syphilis, or some older child has been affected, anti-syphilitic treatment 
must be commenced without waiting for the development of symptoms, in 
the hopes of mitigating the disease or of preventing its development. The 
anti-syphilitic treatment of the parents who have had syphilitic children forms 
an important part of prophylactic management, and may prevent the taint 
from being transmitted from the mother to the foetus. In the treatment of 
infantile syphilis it should be borne in mind that the effects of the poison 
are apt to impair the functions of almost every organ in the body, and in the 
worse cases there is a marked tendency in the direction of anaemia and 
gastro-intestinal atrophy. The dietetics of the syphilitic infant require the 
most careful attention, especially if it has to be artificially fed, as such 
infants are exceedingly likely to suffer from aggravated dyspepsia and 
mal-nutrition. It should, if possible, be suckled by its mother ; if this is 
impossible, it must be artificially fed, as a wet-nurse is not permissible on 
account of the danger of her becoming inoculated by the nasal or other 
discharges from the infant. As soon as the diagnosis is made or the disease 
suspected, mercury must be given in some form or other. The usual plan 
is to give mercury and chalk-powder in half-grain doses twice a day, this 
form of mercury being used on account of its mildness and its being less 
likely to disturb the bowels than calomel. If any looseness of the bowels 
follows its administration, it may be combined with a grain of chalk and 
opium powder or the compound cinnamon powder. In a few weeks the dose 
may be increased from half a grain to a grain : this treatment should be con- 
tinued as long as any of the special symptoms are present, or for some six 
weeks or two months, when the mercury may be omitted for a fortnight or so, 
and the syrup of iodide of iron in five to ten drop doses may be substituted. 
If there is much cachexia or mal-nutrition, a few drops of cod liver oil may 
be added. Instead of the mercury and chalk, some prefer to give calomel 
in one-sixth to one-half grain doses combined with half a grain of saccharated 
carbonate of iron. In Vienna a combination of mercury and tannic acid is 
used (hydrarg. tannicum oxydulatum) when other mercury salts disturb the 
bowels ; the dose is the same as calomel. In obstinate cases, especially 



Hereditary Syphilis 457 

where the skin eruptions are chronic, sublimate baths as recommended by 
Baginsky may be used with good effect. A bath may be taken daily in which 
ten grains of corrosive sublimate are dissolved ; the child should remain in 
the bath some five minutes, care being taken that none of the water gets into 
its mouth. The baths are more cleanly than, and preferable to, the inunction 
of blue ointment, and act with greater certainty. During the time the infant 
is taking mercury the gums should be carefully watched, and any signs of 
stomatitis or sponginess about them should be the signal for at once dis- 
continuing all forms of mercury. It is, however, very rare for salivation to 
occur in children. The coryza should be treated, when the obstruction 
or secretion is excessive, by injections of weak solutions of nitrate of silver 
(gr. i ad ^i) or boric acid ; the dried secretion should be removed, and 
any soreness and excoriation about the nares or lips should be smeared 
with yellow oxide of mercury ointment, which may be applied on a small 
camel's-hair brush. Boric acid may be applied locally as a dusting powder 
to the rash about the genitals or elsewhere. During the relapses mercury 
should be given in some form or other, and the mucous patches and con- 
dylomata which so frequently accompany relapsed syphilis should be fre- 
quently dusted with finely powdered calomel. In the later stages, during the 
tertiary symptoms the solution of bichloride of mercury in doses of half a 
drachm to a drachm, combined with iodide of potassium, should be given 
and continued for many months, when the syrup of iodide of iron may be 
substituted. Tertiary syphilis is apt to be very chronic, the ulcerations of 
skin and caries of bone and corneal affections remaining for months nearly 
stationary, and quickly relapsing when treatment is suspended. Iodoform 
and the yellow oxide of mercury ointments are the most useful local appli- 
cations for the skin and conjunctiva, while a solution of nitrate of silver 
(gr. x ad §i) may be used as an application to the specific ulcerations of 
the mouth and palate. During the treatment of syphilis, both in infancy and 
later childhood, the most generous diet which can be digested must be pre- 
scribed. Abundance of fresh air and change must be insisted on, and the 
most scrupulous care taken to promote cleanliness and to prevent any non- 
syphilitic individual from becoming infected by any discharges from the 
patient. 

In some cases of late congenital syphilis, healing of ulcers or bone 
lesions will only be procured by the use of very large doses of iodide of 
potassium, either alone, or, better still, in combination with mercury. We 
have had to order twenty-grain doses of the iodide three times daily for a 
boy of about twelve before any material improvement was effected. 



45 8 Rheumatism 



CHAPTER XXII 

RHEUMATISM— DIABETES MELLITUS— DIABETES INSIPIDUS 

Rheumatism 

Rheumatism, either in its acute or chronic form, is not common during the 
first four or five years of childhood ; it is commoner after this age, but typical 
attacks of acute rheumatism occur less often in children than in young 
adults. Concerning the etiology and pathology of rheumatism but little 
need be said : hereditary influences, the effects of cold and damp, the 
retention of waste products in the blood, and the poison of scarlet fever, 
and influenza seem in greater or less degree to predispose to or excite an 
attack of rheumatism. 

Scarlatinal synovitis has been fully described (p. 256) ; but it remains to be 
said that, during convalescence from scarlet fever, attacks of what appear to 
be true rheumatism occasionally occur. This is in our experience more 
common in young adults than in children. 

Symptoms. — The symptoms in older children closely resemble those seen 
in adults, except that the attacks can rarely be called acute, but belong rather 
to the category of subacute. The illness sometimes begins with vomiting 
and chilliness, but more often the first thing complained of is pain and 
tenderness in the larger joints, which may become red and more or less 
swollen. The commonest joints to be affected are the larger ones, such 
as the knees, ankles, hips, wrists, and shoulders ; these are rarely all 
affected at the same time or indeed in the same attack ; much more 
commonly one or both knees are distended with fluid, while subsequently a 
wrist or an ankle becomes red, tender, and useless. The joints of the 
cervical vertebrae are often affected, and occasionally some of the smaller 
joints, such as the fingers. There is not often much fever, the temperature 
rarely exceeding 102 . Usually there is not much sweating, the joints 
quickly recover themselves, and the pain and immobility disappear in a few 
days. Sometimes the only evidence of a rheumatic attack is a slight redness 
and tenderness about a single joint. It is the exceeding mildness of these 
attacks as well as the want of intelligence to localise their pains that make 
attacks of rheumatism readily overlooked in young children. A crying out 
when disturbed, with a certain amount of paresis or immobility about a limb, 
may be all there is to indicate an attack of rheumatism, which, mild as it 
may be, is yet perhaps accompanied by endocarditis which may inflict a life- 
long injury. 



Rheumatism 459 

Distinct attacks, however, may be noted in young children, of which the 
following, a patient seen with Dr. Earle, may be taken as an example : 

Acute Rheumatism. — A little girl of twenty-two months was going about as usual on 
March 22 ; on being taken up the next morning she seemed in pain and was unable to 
stand, complaining (apparently) of her left ankle, which was supposed to be sprained. 
The next day, however, the right ankle appeared to be similarly affected, and during the 
succeeding two days her knees, elbows, and neck were attacked successively in the same 
way. On the 27th the knee joints, especially the left, were considerably swollen and hot 
with fluid in the joints ; the next day both joints were equally enlarged. The general 
system was only slightly disturbed ; there was no cardiac affection. The knees remained 
swollen for a few days, but gradually recovered, so that at the end of thirteen days she 
could again walk a little. 

In most attacks the child becomes anaemic. Children, like adults, are 
liable to relapses ; usually fresh joints are affected, with the symptoms 
attendant on the primary attack. In some instances the attacks are of a 
chronic type. Thus stiff neck, or torticollis, as the result of the joints of the 
cervical vertebras being attacked, may be very intractable, and the condition 
suggests caries of the upper cervical vertebrae. However, the symptoms 
usually disappear with a few weeks in bed, with the head fixed between sand 
bags. 

The complications and manifestations of rheumatism are of great im- 
portance, but they are all overshadowed by acute carditis, and it is the danger 
of cardiac lesions supervening that makes us look with so much care and 
anxiety at all joint pains in children. As already remarked (see p. 407) it is 
the exception for children to escape suffering from endocarditis during an 
attack of acute rheumatism, and, moreover, peri-endocarditis may supervene 
with but very slight joint pain, or the latter may come on later. The younger 
the child the more is an attack of acute carditis to be dreaded, inasmuch 
as the mortality is high in the very young, and if the patient survives, it 
is with dilated heart and damaged valves. As already pointed out, the 
pericardium, muscular walls, and endocardium covering the valves are liable 
to take on an inflammation when under the influence of the toxines of rheu- 
matism. The heart cavities dilate, the pericarditis notably increases the 
work of the heart, and an injured mitral also puts the heart at a disadvan- 
tage. The chief danger, however, lies in the damage to the muscular walls 
themselves ; the patient goes on fairly well for a while, then cardiac syncope 
gradually supervenes, and in a few hours perhaps the child is dead. Aftost- 
mortevi examination shows pericarditis in most instances, and as Drs. D. B. 
Lees and Poynton have demonstrated morbid changes in the vessels, interstitial 
tissues and muscle of the heart-wall. In some of our own cases which were 
rapidly fatal, there was only slight pericarditis, and no great dilatation, but 
the muscular wall of the heart was friable, pale in colour and mottled. 

Chorea is another frequent associate of rheumatism, and may either 
precede or follow, or sometimes actually complicate, the rheumatic attack. 
It has been referred to elsewhere. Pleurisy and Pleuro -pneumonia occur 
at times as complications of a rheumatic attack, especially when pericarditis 
is present. Erythema multiforme and Urticaria occasionally occur in 
connection with rheumatism and endocarditis. The erythema may take 
various forms, occurring sometimes as irregular patches of redness, at 



460 Rheumatism 

others as red or white papules. Erythema nodosum is not uncommon. 
In all cases where such forms of erythema occur, the heart should be care- 
fully examined. Purpura occurs also at times in rheumatic attacks. 
Peculiar nodules, first described by Drs. Barlow and Warner, occur in some 
rheumatic cases, mostly in the neighbourhood of joints. They are subcu- 
taneous, the skin being freely movable over them ; they are most common 
at the back of the elbows and wrists, at the ankles, and by the patellae. In 
one case seen by us, that of a girl suffering from severe chorea and rheu- 
matism, there were several hundreds of these nodules, many of them being 
situated over the bones ; friction during the severe movements seemed to 
act as the exciting cause. They were present at the back of the scalp, over 
the spinous processes, along the edges of the scapula, and along the ribs. 
They are not painful, and vary in size fron a split pea to an almond. These 
nodules are, when present, associated with heart disease (see case, p. 520). 
Subacute tonsillitis is not uncommon. 

Diagnosis. — There is often much difficulty in distinguishing the synovitis 
which accompanies rheumatism from one or other of the many other forms 
of synovitis. Thus there is the acute suppurative arthritis of infants, the 
synovitis of septicaemia and scarlet fever, and the synovitis which is apt to 
go on to effusion and has a chronic course which chiefly attacks the knees ; 
there are, moreover, the rarer arthritic attacks which accompany haemophilia, 
syphilis, gonorrhoea, and purpura. It may be impossible definitely to say if 
some arthritic attacks are really rheumatic or not ; their subsequent course 
may possibly clear up the doubt. In infants and young children it may be 
difficult to localise the seat of pain in a limb, and consequently a doubt may 
be raised as to whether in a given case where there is pain and helplessness 
the joints are affected or not. Such difficulty may arise in the epiphysitis of 
congenital syphilis and in the tenderness of the periosteum and haemorrhages 
which are associated with infantile scurvy. 

Treatment. — On the least suspicion of any joint affection in a child it 
should be put to bed between the blankets and restricted to a milk diet. It 
is a comparatively small matter if we are over-cautious in our treatment, in 
keeping at rest in bed a child who has but slight joint trouble and who 
appears to the friends to ail little ; while it is a grave matter to allow a child 
who is suffering from incipient endocarditis to get up and run about, or to 
suffer one to contract endocarditis in consequence of getting up. Knowing 
the readiness with which peri-endocarditis supervenes in mild attacks of 
, rheumatism in children, it is our duty to warn the friends of this, and to 
insist on placing the heart under the most favourable circumstances by giving 
it as little work to do as possible. This is best accomplished by keeping 
the child at rest in bed, perhaps for several weeks after all pain and tender- 
ness have disappeared. 

In the milder cases the only medicine required will be a simple saline 
such as citrate of potash ; the affected joints should be painted with ex- 
tract of belladonna and glycerine, and surrounded with cotton wool. A small 
dose of Dover's powder may be given at night. In the more severe cases 
where many joints are affected and there is much fever, salicylate of soda 
should be given ; five to ten grains may be given every four hours to children 
of from six to eight years of age for two or three days, and then given only 



Chronic Rheumatism — A rthritis — Chronic A rthritis 46 1 

every six hours or three times a day ; it may be prescribed with a saline or 
given with syrup of orange peel. 

In all acute or subacute cases milk is the best form of food ; it may be 
given in combination with potash, soda, or seltzer water ; as long as there is 
any fever this should be adhered to. There is always a risk of a relapse if 
beef tea, soup, or meat is allowed too early during convalescence. Arrow- 
root, rice, and custards may be allowed when all pain has been absent for 
several days and the temperature has been normal for a week. 

Chronic Rheumatism. — Under the terms chronic rheumatism, synovitis- 
or polyarthritis are a certain number of cases of doubtful origin and patho- 
logy. In a few instances what appears to be true rheumatism has a chronic 
course, and certain joints are swollen, stiff and painful for many weeks or 
months. The ends of the metacarpal bones and first phalanges of the 
fingers, as also some of the larger joints, become enlarged, deformed and stiff. 

In syphilitic cases there is at times chronic multiple arthritis coming 
on about puberty, which is apt to be persistent in spite of treatment. In 
some cases there is chronic synovitis with effusion in both knees, with no 
history of syphilis or rheumatism, though the former should always be 
suspected. 

Arthritis deformans or Osteo-arthritis occasionally commences during 
early life, mostly about the age of puberty. It is commoner in girls than 
boys and in those who are weakly and anaemic. The attacks usually begin 
insidiously with stiffness and pain in the small joints of the hand, in other 
cases there is pyrexia, pain and tenderness of the joints, which subsides, and 
later on is followed by another attack. The larger joints sooner or later are 
apt to become involved. As time goes on the joints become more or less 
deformed, creaking is felt on movement, and permanent ankylosis takes 
place. The synovial membranes and cartilage of the joints disappear, the 
ends of the bones are smooth and hard with osteophytic growths at their 
margins. Atrophy of the muscles acting on the joints takes place. 

In some similar cases Heberden's nodes are present. These are small 
nodes of bone on the distal ends of the second phalanges of the fingers, and 
the joints are apt to suffer from subacute inflammatory attacks. Arthritis 
deformans appears but little influenced by salicylates. Cod liver oil inter- 
nally and warm dry heat externally to the joints are the most likely helps. 
Arthritis deformans is closely related to chronic rheumatism, or, at least, is 
with difficulty distinguished from it ; in some of our cases the child has 
suffered from repeated attacks of subacute rheumatism especially affecting 
the fingers, the ends of the bones becoming enlarged and the joints more or 
less stiff ; there has also been endocarditis, but not of the worst type. In 
one case of ours the hips became stiff and distorted. 

Chronic Arthritis. — Sarah E. L., io| years. A year ago began to walk lame and her 
ankles swelled. She went to bed a month after this, and has been bedridden since. She 
has never had acute rheumatism or chorea. The ankles first became swelled, since then 
the knees and wrists; the joints were at first stiff and extended, later they have become 
flexed. She is an anaemic girl and very thin ; both wrist joints are semi-flexed, the left 
especially is almost ankylosed ; the hands are thin, the fingers tapering ; there is much 
thickening over the carpal joints. The hands are in position of 'main en griffe.' The 
ankle joints are also very immobile and the bones thickened. The knees are flexed 



462 



Rheumatism 



(? subluxation), swollen and fluctuating; extension which is very limited causes pain. 
Heart and lungs normal ; no albumen ; there is much muscular wasting. Attempts were 
made by means of chloroform, extension and splints to straighten the knees, but the latter 
lapsed again into the old position. 

Chronic arthritis with glandular and splenic hyperplasia. — This 
form of arthritis, which has been especially described by Dr. G. F. Still, 1 
is not very common in our experience, though Dr. Still has collected 
22 cases, 19 of which he had investigated personally. The disease may 

begin during the first three or four 
years of life, and is specially dis- 
tinguished by a progressive effu- 
sion and enlargement of the joints 
with hyperplasia of the lymph 
glands and spleen. The enlarge- 
ment of the joints differs from 
osteo-arthritis in that there is effu- 
sion into or around the joint, with 
a general thickening. There is 
creaking or grating as in osteo- 
arthritis. Where the joints are 
swollen there is no pain ; in some 
of Dr. Still's cases the chil- 
dren became bedridden through 
chronic flexion of the joints. 
The common joints to be af- 
fected are the wrists and knees, 
later elbows, ankles and fingers. 
There is muscular wasting. 
The most remarkable feature is 
enlargement of the glands and 
spleen. This glandular hyperplasia 
suggests Hodgkin's disease ; the 
axillary glands and glands in the 
groin and posterior triangle of 
the neck are most often affected. 
The mesenteric, hepatic, and 
splenic glands may also be en- 
larged. The spleen seems con- 
stantly to be enlarged. Anaemia is present, and there is periodical pyrexia. 
The course of the disease is chronic. There seems to be a special liability 
to pericarditis and pleurisy. In our own case, we were suspicious of Hodg- 
kin's disease on account of the enlarged glands and spleen, and erratic febrile 
attacks. At the post-mortem the enlarged glands were pale and by no means 
unlike the glands seen in that disease. It seems unlikely that the glandular 
enlargement is merely secondary to the arthritis, but what the connection 
is it is not possible to say. 

The following case evidently belonged to the same group of cases as 
those described above : 

1 ' On a form of chronic joint disease in children,' Med. Chi. Trans., vol. 80. 




Fig. 94. — Chronic Arthritis with Glandular Enlarge- 
ment. The dotted lines show the lower limit of 
the liver and spleen. Boy aged 3 years. 



Chronic Arthritis — Diabetes Mellitus 463 

Joseph M., aged 3 years, was admitted to the Children's Hospital, November 2, 1896. 
The mother states that both the father and brother have had rheumatism. In February 1896 
the child had scarlet fever badly ; the attack was followed by dropsy. Three months after 
he suffered from rheumatism, a number of joints becoming affected at the same time ; 
they were painful, but are not so now. He has always been a pale child. There was no 
history of syphilis. On admission, it was noted that both wrist joints were puffy and 
swollen, having a pulpy feel, more like a tubercular joint than rheumatism ; both knees were 
also swollen and flexed, though they could be straightened without pain. There was no 
pain or tenderness in the joints. The glands in the axillae, Scarpa's triangle, and posterior 
triangle of the neck were enlarged, but not tender (see fig. 94). There was well-marked 
enlargement of the spleen and also of the liver. The boy was pale ; there were 2,700,000 red 
corpuscles per cub. mill. , no relative excess of leucocytes or eosinophile cells. Heart and 
lungs normal, urine normal. Temperature erratic, 96 -iO4° F. Fluid withdrawn from 
knee-joint contains leucocytes, no tubercular bacilli. November 6. — Slight swelling of left 
elbow-joint. December 2. — Temperature continues erratic ; some evenings it rises to io4 : ; 
joints contain less fluid. December 15. — Some swelling of dorsum of right foot. Tem- 
perature erratic. He developed broncho-pneumonia, and died January 9, 1897. The 
disease had existed about 6 months. Post-mortem, — Body fairly well nourished, very 
anaemic. Knee-joints, ankles, elbows contain fluid, thickened synovial membrane, over- 
growth of bone and cartilage ; ends of metacarpal bones enlarged, joints contain fluid. 
Axillary glands, glands in groin and neck much enlarged, and of a pale colour. Heart 
normal. Lungs broncho-pneumonic. Mesenteric glands enlarged. Liver enlarged, 
glands large and white in fissure. Spleen enlarged, 5! oz. , indurated glands in hilus also 
large and white. Kidneys normal. 

Diabetes Mellitus 

Though diabetes is much less common in children than in young adults, 
it cannot be said to be rare, as Gerhardt has recorded 1 1 1 cases at various 
ages, from six months to fifteen years. Cases have been observed in infants 
at the breast, though the diagnosis in such may be open to doubt on account 
of the difficulty of obtaining the urine, and of the uncertainty of detecting 
small quantities of sugar in the urine. Little can be said about the etiology 
of these cases ; a history of diabetes in the family may, however, often be 
obtained. Thus, in a family we are acquainted with, two uncles died of 
diabetes, and two children, brother and sister, aged 14^ years and 3^ years. 
Another sister of 6^- years has sugar occasionally in the urine. 

The symptoms noted are those which are present in adults. There is 
the harsh dry skin, red tongue, marked thirst, and voracious appetite. There 
is often incontinence of urine on account of the large quantities passed. The 
specific gravity of the urine is high, 1030 to 1040 or more, and perhaps 5 per 
cent, or even 10 per cent, of sugar may be found. The child usually wastes, 
especially if not carefully treated, and is apt to contract a fatal pneumonia. 
Tuberculosis or chronic phthisis may supervene as in adults. Diabetic coma 
is not uncommon. The symptoms commence with headache, dry tongue, and 
dyspnoea, followed by coma. It is well to bear in mind the possibility of being 
called to see a child who has rapidly passed into a state of coma without 
diabetes having been suspected. 

The prognosis is mostly unfavourable, though cases are recorded which 
made apparently a permanent recovery. In the fatal cases the duration 
varies from a few weeks to a year. 

Treatment. — All starch-containing foods and sugars should be forbidden, 
gluten bread and saccharin being substituted. Milk in moderate quantities 



464 Diabetes Mellitus — Diabetes Insipidus 

or cream may usually be allowed, as children are much more dependent 
upon milk as a food than are adults. Beef tea, soups, fish, chicken, and 
butcher's meat, with gluten bread and green vegetables, will chiefly form the 
diet. Much difficulty is often experienced in keeping children to a rigid 
diet, as they long for bread-and-butter or puddings. With regard to drugs, 
codeia (gr. £ to gr. |) or opium should be given, while the bowels are carefully 
regulated with Carlsbad salts or Rubinat water. Great care should be 
exercised to prevent the child catching cold or any of the zymotic diseases, 
since bronchitis, whooping cough, or scarlet fever is almost certain to 
unfavourably affect the course of the disease. 



Polyuria — Diabetes Insipidus 

The etiology of this condition is for the most part quite unknown, and it 
probably owns a variety of causes. Cases of brain disease, of contracted 
kidney, tuberculous kidney, and of functional diseases of the alimentary 
canal may be accompanied by polyuria. In the majority of cases no cause 
can be assigned, and we are obliged to speak of such as idiopathic, much in 
the same way as we speak of idiopathic anaemia. In a large class of cases 
polyuria is temporary only. Children, often girls between three and six 
years, are noticed to wet their beds, or make water in the day time far more 
frequently than they have been accustomed to. In the same way boys will 
wet their trousers frequently during the day when it was thought that they 
had grown sufficiently old to have learnt proper habits. An examination in 
such cases will probably show no abnormal constituent of the urine, but that 
it is of low specific gravity, perhaps 1005 to 1010, and passed in larger amount 
than usual. Possibly there may be a trace of albumen. In the majority of 
cases this condition will be found to depend upon digestive derangements or 
improper feeding ; it appears to be a reflex irritation of the kidneys, the 
source of irritation being in the intestine, the presence of an intestinal catarrh 
being the cause. Possibly also the deposition of uric acid salts in the kidney 
may be the cause of a large quantity of watery urine being secreted. The 
presence of thread worms or round worms in the intestine or rectum also 
appears at times to produce polyuria. In those rare instances of contracted 
kidney occurring in childhood large quantities of urine are sometimes 
passed ; in such cases the specific gravity is low, but there will usually be 
some albumen. 

In those cases to which the name of 'Diabetes insipidus' is usually 
applied there is intense thirst, and large quantities of pale urine with a 
specific gravity of 1002 to 1005 are passed. A girl of Z\ years under our care, 
who had suffered for some six months, drank as much as ten quarts in 
twenty-four hours, and passed a proportionately large quantity of water. 
When restricted to ten pints of fluid daily, she would in the night crawl 
under the beds to the bath-room to obtain water, or surreptitiously drink her 
own urine. Such patients have dry, rough skins, are anaemic, and of irritable 
temper. The course of such cases is exceedingly chronic, and ftost-moi'tems 
are seldom obtained. 



Diabetes Insipidus 465 

Treatment. — The treatment must depend on the cause. If simply reflex, 
dependent upon intestinal irritation, a calomel purge may be given and a 
carefully restricted diet prescribed. In confirmed cases of Diabetes insipidus 
various drugs have been tried : opium, strychnine, valerian, and ergot usually 
fail ; in our own case no drug seemed to check the secretion of urine in the 
least — a temporary improvement took place during an intercurrent attack of 
tonsillitis. In all cases the patient should be warmly dressed and protected 
from cold, as a chill has the effect of checking the perspiration and so in- 
creasing the secretion of urine. 



H H 



466 Diseases of the Nervous System 



CHAPTER XXIII 

DISEASES OF THE NERVOUS SYSTEM 

Introduction. — The student who has gained his knowledge of the 
diseases of the nervous system entirely among adults, will be certain to find, 
when he comes to see the same class of diseases among children, that the 
difficulties of diagnosis are much greater in the latter, and that some diseases 
which are rarely met with among adults are common enough among children. 
This is no doubt true of disease in children generally, but it is especially 
true of the nervous system. For instance, he will find very early in his 
career that it is often exceedingly difficult to estimate the amount of pain 
from which a child or infant suffers. An infant or peevish child will cry 
from fear, discomfort, or bad temper just as loudly as from the severest pain, 
and it may be quite impossible to localise the seat of pain or, indeed, to find 
out what it is crying for. There may be a general hyperesthesia present, 
but it will be mostly very unsafe to draw any conclusions from this symptom 
alone as to the presence of organic disease, though it may be borne in mind 
that hyperesthesia is frequently present in the early stages of meningitis. 
The infant's legs may hang down helplessly, and he may at first think that 
they are paralysed, but a closer examination discloses the fact that there is 
some epiphysitis or periosteal tenderness which prevents the child from using 
the limbs. On account of the readiness with which reflex disturbances are 
evoked in the young, we often find ourselves in difficulties and in error. Thus 
the infant has one-sided convulsions ; are these due to a serious lesion on the 
opposite side of the brain, or to an intestinal catarrh or colic? How often 
the differential diagnosis between gastric and cerebral vomiting in infants is 
difficult and for a time impossible ! The nervous system of the young is 
easily upset by a high fever or a poisoned condition of blood, and there may 
be drowsiness, retraction of the head, and convulsions — symptoms which 
naturally suggest cerebral disease, such as meningitis. 

Among the diseases which are much commoner in the young than in the 
old, meningitis stands pre-eminent, and assumes in consequence a position 
of great importance. It occurs alike in apparently healthy and robust 
infants and children, and in those whose history and symptoms suggest 
tuberculosis in some of its phases. Cerebral haemorrhage from a ruptured 
artery is rare in the young, but an extensive bleeding may take place on 
the surface of the brain from over-distended veins or capillaries, and give 
rise perhaps to a lifelong hemiplegia. Convulsive disorders — the spasms 
being local or general — are vastly more frequent during the first two or three 



Clinical Examination 467 

years of life than at any other period, and their results much more serious. 
The infant may die in a convulsion from spasm of the glottis, or a meningeal 
haemorrhage may take place, and a serious injury to the brain may be thus 
caused. Among other diseases which are of greater frequency in early than 
in later life, acute atrophic paralysis and chorea may be mentioned. 

Clinical Examination. — The shape and size of the skull are of impor- 
tance as giving some indication of the size and configuration of the brain. 
The condition of the skull may be investigated by inspection, palpation, and 
mensuration ; neither auscultation nor percussion yields any indications of 
much practical importance. By inspection a general idea may be obtained 
of the shape of the head, whether large (macrocephalic), small (micro- 
cephalic), asymmetrical, long (dolichocephalic) as in the negro, round 
(brachycephalic) as in the Mongols, hydrocephalic, or square as in rickets. 
By means of palpation the condition of the fontanelles can be ascertained, 
whether bulging, as in hydrocephalus ; or depressed, as in anaemia ; or widely 
open for the child's age, as in rickets. The edges of the bones may be felt 
to ascertain if they are thickened ; the parietal or frontal eminences may be 
unduly prominent, or various bosses may be present, as pointed out by 
Parrot. Undue thinness of the skull, more especially of the occipital, may 
be detected by firm pressure with the fingers, the bone being felt to bend or 
yield beneath the fingers. By means of mensuration, using calipers and a 
thin flexible piece of lead wire, a tracing of the outline of the skull, both 
longitudinally and transversely, may be made, and a graphic record, thus 
made, kept. In this way the frontal or occipital regions may be shown to 
be smaller than normal, or one parietal region may be flatter than the other, 
as in some cases of deficient development or injury at birth. 

It is convenient to remember that, roughly speaking, the average circum- 
ference of a child's head is 14 in. at birth, 16 in. at six months, 18 in. at a 
year old, 20 in. at two years, 21 in. at four years, and after this the increase 
is slight. At twelve or thirteen years old, 2\\ in. would be an average. We 
must, however, remember that there are large heads and small heads without 
there being any abnormal condition of brain. In children over a year old a 
head measuring 17 in. or under would suggest imbecility. 

The clinical examination will necessarily include observations on the 
condition of the muscles to see if any paresis or paralysis is present. A 
slight squint is easily overlooked, and the friends may have to be appealed 
to for their observations, as the squint may be present at one time and 
absent at another. The condition of the pupils must be observed, and it 
may be necessary to examine the optic discs and to test the refraction of 
the eyes. If there is any question of paralysis, the child should be examined 
when naked, and if it can walk, the character of its gait observed. The 
condition of the reflexes, especially the knee-reflex, and the presence or 
absence of ankle-clonus observed. An exaggerated knee-reflex with ankle- 
clonus is usually present in old cases of ' birth paralysis,' and in pressure 
myelitis when the disease is situated above the lumbar enlargement. But 
these phenomena are certainly also present in some cases of hysterical 
paraplegia, especially when the paresis has lasted some time. We have 
twice seen exaggerated knee-reflex, both times in boys, following an ill- 
defined feverishness (possibly influenza) lasting several weeks, and finally 



4°° Diseases of the Nervous System 

ending by completely disappearing. The absence of knee-reflex suggests 
peripheral neuritis. Ankle-clonus is also seen in old-standing disease of the 
tibia when the leg has been in splints. 

Cerebral Congestion. — A passive congestion of the venous system 
inside the skull takes place whenever respiration ceases or is impeded, in 
consequence of an over-filling and distension of the right side of the heart. 
This is markedly so during a convulsion and in acute general bronchitis. 
Does an acute active congestion take place without passing on into an acute 
meningitis ? This question is difficult to answer. Certainly cases occur 
which suggest this. Thus we have seen school children, both boys and 
girls, who have been working hard at examinations, suffer from headache, 
vomiting, prostration, rigidity of the muscles of the neck, squint — symptoms 
which suggest cerebral irritation or an early stage of meningitis — recover 
entirely, after a few days' rest in bed, under the influence of bromides. We 
must not, however, forget that any symptoms of cerebral irritation in the 
young are extremely suggestive of a miliary tuberculosis of the arteries 
of the brain, which may be followed at any time by the symptoms of 
meningitis. 



Meningitis 

Tubercular Meningitis. — In tubercular meningitis there is an inflam- 
mation of the pia mater, set up by the presence of tubercles on the vessels, 
more especially at the base of the brain. While tubercles and meningitis 
are very commonly found associated together post mortejn^ it must be borne 
in mind that a simple or non-tubercular meningitis is not uncommon, and also 
that tubercles may be present on the vessels without any meningitis, though 
the probabilities are great that if tubercles are present they will sooner or 
later light up inflammation of the meninges. Another point must also be 
remembered : that a meningitis so called is in reality a meningo- encephalitis ; 
the vessels which penetrate the grey matter of the convolutions being certain 
to join in the inflammation 

Tubercular meningitis is less common in children under the age of one 
year than in older children ; simple or posterior basal meningitis is rela- 
tively more common at this period, though the tubercular form certainly 
does occur, but on account of the difficulty of distinguishing between simple 
and tubercular meningitis in infants and young children we are often not 
justified in making a differential diagnosis in the absence of a post-mortem. 
Between the age of one year and the commencement of puberty tubercular 
meningitis is a common disease. 

It rarely happens that the pia mater is the first part of the body to be- 
come the seat of tubercle ; a tubercular meningitis is in the large majority 
of cases preceded or at least accompanied by grey granulations or caseating 
tubercle in some other part of the body. A tubercular meningitis is often 
the closing act of a general tuberculous process ; it may occur early or late, 
and, when once established, quickly brings the end. The post-mortem evi- 
dence of this is clear and decisive, for in the bodies of those dying with 
tubercular meningitis grey granulations or caseating tubercle will almost 
certainly be found either in the lungs, bronchial glands, brains, spleen, or other 



Tubercular Meningitis 469 

organs. Clinically the same thing is also evident : children suffering from 
hip-joint disease, spinal caries, caseating cervical glands, or chronic tuber- 
cular peritonitis, are not infrequently cut off by an intercurrent attack of 
tubercular meningitis, or the latter follows whooping cough, measles, or 
pneumonia. In the large majority of cases there is a definite history of ill- 
health before the actual brain symptoms supervene. An exception to this 
i s, however, seen in the case of infants and children under two years of age, 
in whom occasionally the attacks are sudden, supervening in the midst of 
apparent health. 

What determines the growth of tubercle on the pia mater and the subse- 
quent meningitis ? No certain answer can be given to this question. It is 
easy, and perhaps natural enough, to attribute it to over-excitement of the 
brain, or excessive brain work ; and possibly this may be so in some cases 
in tubercular children, who have been badly fed and subjected to unfavour- 
able life-conditions, while their brains are being driven at the highest pressure ; 
but such cases must be exceptional. It must be borne in mind that tuber- 
cular meningitis attacks children a: few months old and children in hospital, 
and under conditions in which it is impossible that over-brain work can have 
had anything to do with the supervention of the meningitis. We cannot say 
why the tubercular process should in one case attack the brain and in other 
cases the peritoneum, or lungs, or spine. 

Symptoms and Course. Premonitory. — The onset is insidious and the 
early symptoms are ill-defined, being those of general malaise rather than 
of actual disease. In most cases there is a history of ill-health for several 
months, perhaps succeeding an attack of measles or whooping cough, during 
which time the child has wasted or lost flesh and become flabby. There 
may have been cough, dyspepsia, constipation, loss of appetite, otitis, en- 
largement of glands, or more or less feverishness, especially at night ; such 
symptoms are not in any way distinctive, and are often the result of a chronic 
intestinal or gastric catarrh : yet, if there is a family history which suggests 
tubercle, they necessarily excite suspicion. In some cases definite brain 
symptoms precede by many weeks the actual attack of meningitis, and then 
perhaps pass away or remit for a while. Among these may be men- 
tioned headache, squint, a staggering gait, an unusual tendency to fall, a 
temporary loss of control over the sphincters. The late Dr. Oxley records a 
case in which the boy's disposition entirely changed, and he showed a constant 
tendency to bite on the least provocation ; often there is extreme irritability, 
which is all the more suspicious if it occurs in a good-tempered child. Such 
symptoms are possibly due to the irritation caused by the presence of tubercles 
on the vessels or in the brain, which may perhaps precede for some time the 
attack of meningitis ; or it is quite conceivable that a temporary congestion 
or even a patch of meningitis may be present. 

. It is impossible during the premonitory stage to do more than suspect 
the onset of tubercular meningitis or tuberculosis in some form or other ; in 
a large number of such suspected cases recovery gradually takes place with- 
out any definite diagnosis having been arrived at ; in these cases, however, 
we are hardly ever warranted in assuming that our treatment has been the 
means of warding off an attack, and we may be left in ignorance as to its nature. 
In some cases, especially in infants, there are no preliminary symptoms : the 



470 Diseases of the Nervous System 

infant, while in apparent health, begins to vomit and gradually becomes 
comatose, or almost the first symptom which attracts attention may be a 
hemiplegia. In such cases a simple meningitis is perhaps suspected, but the 
post-mortem usually shows it to be tubercular. 

The premonitory symptoms gradually pass into the first of the three 
stages into which the attacks are usually divided — namely, the stage of excite- 
ment. At the commencement of this stage the symptoms may be chiefly 
gastric, or they may be definitely cerebral from the first. In the former 
case the most prominent, and indeed sometimes for several days the only 
symptom, is vomiting. This may begin after a meal and be attributed to 
some improper food, but it continues in spite of the most careful dieting, is 
usually accompanied by a clean tongue, and, while aggravated by food, often 
recurs, with much retching and nausea, when the stomach is empty. Too 
much stress must not be laid on the character of the vomiting, and perhaps 
for a few days a doubt may be entertained as to its true nature, whether due 
to cerebral disease or gastric irritation. The vomiting of meningitis is usually 
erratic, coming and going without any apparent cause. At this stage the 
child may be perfectly intelligent, and no direct cerebral symptoms may be 
present. Constipation is usually present : the abdomen, which is at first 
rounded, becomes flabby, and later retracted, from the contraction of the 
intestinal walls which takes place. Before long other symptoms, more 
directly pointing to the head, become developed. There are headache, giddi- 
ness, great irritability, intolerance of light and noise. The child likes to be 
nursed by its mother, lies on her lap, and resists the interference of others. 
Its temper has completely changed ; it is feverish and extremely irritable. 

The symptoms may be more definitely cerebral from the first, and the 
vomiting may not be a prominent symptom. The child complains of head- 
ache, which is often intense ; there is giddiness and staggering gait ; its 
sleep is disturbed by dreams, or it wakes up with a shrill cry of distress, 
often of a piercing character, and known as the ' hydrocephalic cry.' The 
child neglects its toys, preferring to lie quiet and undisturbed. The pulse is 
usually quickened, the temperature raised a degree or two at night, and the 
tongue becomes coated with fur, which has often a brown or yellowish tinge. 
Remissions are apt to occur, and for a while perhaps the little patient is 
again himself, bright and chatty, and ready for his toys, but to the dis- 
appointment of the friends the old symptoms return with greater intensity. 
So far the symptoms have been those of cerebral excitement, caused in all 
probability by the inflammatory congestion of the pia mater which is present ; 
following this, comes the stage in which effusion is taking place and the 
brain functions become more and more effaced. 

The second stage, often called the stage of tra?isition, is marked by the 
commencement of drowsiness. The child becomes more and more dull and 
heavy ; it is no longer found on its mother's lap, but in bed, in a half-drowsy 
state. It likes to lie quiet, does not wish to be disturbed, and if roused it 
answers in a snappish manner and then curls up again and is off to sleep. 
The vomiting now is usually less urgent or perhaps ceases ; the abdomen is 
retracted, the bowels confined. The pulse is usually slower than in the 
earlier stages, and is frequently irregular and hesitating. Commencing optic 
neuritis may be observed, but the child in this stage will often keep its 



Tubercular Meningitis 471 

eyes spasmodically closed, so that observations on the discs are rendered 
difficult. The edges of both discs appear blurred and indistinct, from the 
presence of swelling ; the veins become distended and tortuous, but the 
changes are never so marked as they are when a cerebral tumour is present. 
The intensely congested and swollen discs, with various minute haemorrhages 
so often seen in other forms of cerebral disease, never occur, possibly because 
there is not sufficient time for these extreme changes to develop. Miliary 
tubercles may be present in the choroid, but these — as far, at least, as our 
experience goes — are chiefly present in cases of general miliary tuberculosis. 
Various other phenomena are apt to supervene, such as convulsions, muscular 
twitchings, paralyses, and spastic contraction of the muscles of the neck and 
back, less often of the limbs. The convulsions may be general and bring 
about a fatal result, especially in young children. The paralyses may involve 
the muscles of the eye, face, or limbs of one side. Some retraction of the 
head is common : sometimes it is so extreme that the back of the head comes 
in contact with the spine ; the back is frequently arched. There is often a 
spasmodic contraction of the masseters, so that the child grinds its teeth, 
making a peculiar and unpleasant grating sound. There is apt to be incon- 




Fig. 95. — Tracing of Movements of Chest Walls from a case of Meningitis, showing 
' Cheyne-Stokes ' respiration. (After Landois and Stirling.) 

tinence of the urine and faeces. As the child becomes more and more 
drowsy the respirations become altered in character, approaching the 
' Cheyne-Stokes ' type — i. e. the respiratory movements become shallower and 
shorter, until they cease ; then a distinct pause in the respirations takes place, 
to be followed by a deep, sighing inspiration, which is again followed by a 
series of shallow respiratory movements, or the pause is followed first by 
shallow then by deeper respirations, as in fig. 95. The pause in deep coma 
may last for several seconds ; we have once or twice timed an interval of ten 
seconds. 

From a condition of drowsiness the child passes into the third stage, or 
stage of coma. It can no longer be roused 01 recognise its friends ; the con- 
junctivae become insensible, the pupils dilated and sluggish, and the 
optic discs can be examined without difficulty. The muscles of the limbs 
and abdomen are weak, flabby, and toneless. The tongue is coated with 
a thick brown fur, and sordes appear on the teeth and black crusts on 
the lips The skin is harsh and dry, and the wasting extreme. Excessive 
secretion takes place from the conjunctivae, so that the eyes are smeared 
with mucus or pus. The pulse becomes weak and rapid. The coma is 
usually profound, so that the child cannot be roused even for a moment, 



47 2 Diseases of the Nervous System 

but usually the power of swallowing is retained to the last. In this miser- 
able condition the patient lasts for many days, perhaps a week, and even 
after it appears moribund slight improvement may take place. The total 
duration of the disease is usually about three weeks, but, especially in young 
children, death often takes place much sooner. 

The temperature throughout the course is most uncertain, but always o 
an irregular, intermittent type, sometimes varying three or four degrees during 
the twenty-four hours ; at other times the flights are much less marked. The 
temperature is of course modified if there is an extensive tubercular process 
in progress in the lungs and other parts. Hyperpyrexia is not uncommon ; in 
one case, that of a boy of three years of age, who was convulsed, the temperature 
rose to 108 F. (rectal temperature) shortly before death. The post-mortem 
showed tubercular meningitis, caseous mediastinal glands, and some miliary 
tubercles in the spleen and kidneys. The lungs were free. The paralyses 
which are apt to occur are seldom marked, often only temporary, being rather 
paresis than paralysis ; sometimes, however, when extensive softening takes 
place in one hemisphere from thrombosis of some large vessel, the paralysis 
of an arm, or arm and leg, may be complete. Anaesthesia is rarely, if ever, 
present ; hyperesthesia is not uncommon in the early stages, but more as a 
part of a general irritability than anything else. 

Whilst in typical attacks the various stages are fairly well marked, cases 
are frequently met with which are extremely irregular, the typical symptoms 
are absent, and no diagnosis is made until the child is comatose and moribund. 
In such cases the symptoms may be indefinite for a week or two, then a 
marked improvement takes place, which gives hopes that our diagnosis of 
meningitis is incorrect, then suddenly convulsions and coma supervene and 
death speedily occurs. The fact that a remission of many of the symptoms 
may take place, the child being decidedly improved for a while, must be 
constantly borne in mind. In other cases the course is short and sharp, in 
this respect resembling some cases of simple meningitis. Thus, for instance, 
a boy of eight years, who came of a tubercular family, attended at school till 
April 23, though for the last few days he had not felt well. He then stayed 
at home on account of cough and weakness ; he began to vomit on May 3 ; 
the next day he became drowsy, gradually passing into coma, and died on 
May 8. At the post-mortem miliary tubercles, with some pneumonia, were 
present in the lungs and in the abdominal organs ; there was also tuber- 
cular meningitis, with much fluid in the lateral ventricles and subarach- 
noid space. 

In infants of six months and under, the symptoms are often the reverse 
of characteristic ; the infant perhaps vomits food, but in other ways appears 
quite well, and the vomiting is not unnaturally looked upon as due to some 
gastric irritation ; then possibly some rigidity of the muscles of the neck and 
slight retraction of the head are noticed, and it gradually passes into a con- 
dition of drowsiness and coma. Muscular twitchings of the facial muscles 
or frequent clonic spasms of the muscles of a limb or arm may be present. 
In other cases the infant appears to be ' teething,' there is some slight fever 
and restlessness, but nothing to indicate cerebral disturbance ; then suddenly 
convulsions come on, followed by hemiplegia, and perhaps coma. The 
state of the fontanelle is often a help in diagnosis in doubtful cases, as is also 



Tubercular Meningitis 473 

the rigidity of the muscles of the neck and consequent retraction of the head. 
The fontanelle is full and bulging, and in the later stages the veins on 
the forehead may be more prominent than usual, and the head may actually 
enlarge from the presence of an excess of fluid in the lateral ventricles. The 
retraction of the head is not diagnostic, it occurs in cases of posterior basal 
meningitis, and sometimes it appears to be the result of reflex irritation from 
the pulmonary and abdominal viscera. It occurs also in otitis. Posterior 
basal meningitis (see p. 479) is a commoner disease in infants under six months 
than tubercular meningitis, and a differential diagnosis in the early stages is 
difficult. 

Prognosis. — As soon as a diagnosis of tubercular meningitis is made 
there is little hope of recovery. In any case the hope must be rather that 
our diagnosis is wrong than to expect a permanent recovery to take 
place from tubercular meningitis. Yet undoubtedly the meningitis pro- 
duced by the presence of tubercle does not always kill at once, and, 
moreover, in any case there is the hope that the meningitis is a simple one 
without the presence of tubercle. We have seen at least three cases — in 
which there was good evidence to show that the patients were suffering from 
tubercular meningitis — recover for a time and die subsequently of a second 
attack or of a general tuberculosis ; one of these cases may be shortly 
referred to. 

Tttbercular Meningitis. Temporary Recovery. — Mary S. , aged 6| years, was quite 
well till a month or two before admission to hospital, when several ' cold abscesses ' 
formed on her legs and discharged. Lately she has had headache, been giddy, staggered 
in her gait, and rambled at night. For several nights after admission she was restless, 
and screamed with pain shooting through her head ; an internal squint was noted in the 
left eye ; she was fairly sensible in the daytime, but complained of headache, and fre- 
quently passed her motions under her ; there was occasional vomiting. She was treated 
with ice to her head and complete rest in bed, and bromides. There was slight optic 
neuritis, which gradually subsided during her stay. She gradually improved, and was 
discharged after a three months' stay, apparently quite well. She was readmitted six 
months after with undoubted signs of meningitis, and died after a fortnight's illness. 
The post-mortem showed miliary tubercles in the lungs, cheesy nodules in the liver, recent 
tubercles on the vessels at the base of the brain, and recent lymph ; there was also very 
distinct fibrous tissue at the base, as if resulting from a past inflammation; the inter- 
peduncular space was matted, so that the third and fourth nerves had to be dissected out 
and cleaned of fibrous tissue, and the lobes along the Sylvian fissures were firmly matted 
together. The history of the case and the post-mortem appearance made it clear that a 
recovery had taken place from a basal meningitis in a tubercular subject. 

A permanent recovery from an attack of tubercular meningitis means in 
the vast majority of cases a recovery from a general tuberculosis — a result 
which is improbable. The prognosis becomes bad in the extreme when 
the patient has sunk into a drowsy condition and Cheyne-Stokes respiration 
is present, though several days may elapse before the end comes. 

Diagnosis. — In a disease which begins so insidiously and assumes such 
varied forms the diagnosis is necessarily difficult. It must be in the 
experience of most to have made mistakes in diagnosis, in suspecting the 
onset of tubercular meningitis when the patient was suffering from some 
dyspepsia or intestinal catarrh, and, on the other hand, making light of the 
anxieties of the friends when subsequent events have justified their fears. As 



474 Diseases of the Nervous System 

regards diagnosis in the early stages too much stress must not be laid on 
irritability, grinding the teeth at night, loss of appetite, wasting, and sleep- 
lessness, as these may be symptoms of a perfectly recoverable disease. On 
the other hand, sickness, giddiness, frequent stumbling, staggering gait, 
temporary squint, loss of power of the sphincters, even though these remitted 
after a while, would justify grave suspicions. They may indicate the presence 
of tubercle or some irritation of the brain, which may be quickly followed by 
definite symptoms of meningitis. 

The principal errors which are likely to be made may be summed up as 
follows : 

i. Mistaking the vomiting of meningitis for simple gastro-intestinal dis- 
turbance. This is a very common mistake in the early stages of mening- 
itis ; the vomiting of meningitis, like the vomiting of gastric catarrh, usually 
follows the ingestion of food, but it may also follow any movement of the 
patient ; it may occur when the stomach is empty and the tongue clean. 
The vomiting of a gastric disturbance mostly ceases after the stomach and 
bowels have been unloaded, while a cerebral vomiting is continuous in spite 
of treatment. In any case of causeless vomiting in a child a careful 
look-out must be kept for more definite brain symptoms, such as con- 
vulsions, dilated sluggish pupils, retracted head, and retracted abdomen. 
A hesitating or intermittent pulse would strongly suggest the onset of 
meningitis. The past history of the patient is often important. The 
vomiting and convulsions present at times during dentition may be a 
source of difficulty. 

2. The mistake may be made of attributing to meningitis symptoms 
which are due to the presence of some febrile disorder or reflex irritation. A 
child cutting his teeth may be irritable, feverish, drowsy, and may start in 
his sleep, simply from the effects of dentition or from undigested or improper 
food in his alimentary canal. The sudden onset of fever is against men- 
ingitis, as also is evidence of dyspepsia, such as flatulence and colic ; the 
condition of the gums should be carefully examined. A few days would 
decide the diagnosis. The diagnosis between typhoid and meningitis 
is not usually difficult, that between typhoid and acute miliary tuber- 
culosis being often much more so. The symptoms presented by a child 
sickening for typhoid may not be unlike those presented in the early stages 
of meningitis ; vomiting, however, is not a symptom of typhoid : the fever 
present and the condition of the abdomen would usually decide the diagnosis. 
The possibility of a simple meningitis occurring" in the course of typhoid or 
pneumonia must be borne in mind, though it is not a common complication 
in either case. 

3. At the end of certain exhausting diseases, such as acute diarrhoea, 
marasmus, &c, in infants, cerebral symptoms due to arterial anaemia of 
the vessels of the brain are apt to arise, such as convulsions, coma, con- 
tracted pupils, convergent squint, &c. This condition has been called 
'false hydrocephalus. 5 The history of the case, the depressed fontanelle, 
the almost pulseless condition of the infant, and the rapid onset and course 
of the ' false hydrocephalus, 3 would usually distinguish it from meningitis. 

The differential diagnosis between tubercular and non-tubercular men- 
ingitis is often impossible. A family history of tubercle or a history of the 



Tubercular Meningitis 475 

individual having suffered from caseous glands or other tubercular manifes- 
tations, or having recently suffered from whooping cough or measles, would 
naturally favour a diagnosis of the tubercular variety, as would also an 
insidious onset. On the other hand, the history of a blow, or an otitis, or 
exposure to a hot sun, and a stormy onset, would favour the diagnosis of 
the non-tubercular form. 

The diagnosis between acute meningitis and otitis is often difficult, and 
yet it is of the greatest importance. The relation between the two conditions 
is somewhat complex : a meningitis may undoubtedly arise from contiguity 
of diseased bone in the ear or acute suppurative otitis ; a purulent meningitis 
may exist with suppuration in both tympanic cavities, or the latter cavities 
may contain cloudy fluid only, under circumstances which make it probable 
that the meningitis and otitis are both dependent on the same cause, and are 
not related as cause and effect. There is much reason to believe that an 
acute suppuration in the middle ear may closely simulate acute meningitis, 
and there is little doubt that they have often been mistaken one for the 
other. Cases which have been diagnosed as acute meningitis have quickly 
recovered after a discharge of pus from the ear, either bursting through the 
tympanic membrane spontaneously or being relieved by incision. In cases 
of double suppurative otitis there may be intense pain in the head, fever, 
delirium, convulsions, optic neuritis, and deafness. The point of greatest 
diagnostic importance is the deafness without facial paralysis ; for, as 
Gowers points out, meningitis 'never gravely injures the auditory nerve 
without the adjacent facial nerves ; ' nevertheless the diagnosis between 
otitis and otitis with superadded meningitis is exceedingly difficult and 
often impossible. 

Morbid Anatomy. — The bodies of those who have died of tubercular 
meningitis are usually wasted in a high degree, but in some acute cases they 
may be fairly nourished. On removing the skull-cap and exposing the 
convex surface of the bram the veins on the surface will be found to be 
unusually full of blood ; the convolutions are flattened, having been com- 
pressed by the distended lateral ventricles, and their surfaces are dry and 
sticky. More or less purulent-looking lymph is present : it may be usually seen 
on the lateral, less often on the convex, surface. On examining the base, the 
effusion of lymph will be found to have taken place much more freely than 
on the convex or lateral surfaces. The Sylvian fissures will be seen to be 
matted with lymph ; the interpeduncular space, with the optic commissures 
and tracts, the third, fourth, and eighth nerves, and the inferior surface of 
the pons, and cerebellum, will be found in the same condition. Lymph 
may generally also be found around the medulla and spinal cord. An 
examination of the small arterial branches will show that they are studded 
with minute grey or yellowish tubercles ; the lumen of some may be 
occluded with thrombi. 

In some cases hardly any lymph will be found, but the arachnoid is 
opaque and there is more or less effusion of cloudy fluid beneath it, while 
the brain substance is cedematous and watery. 

Important changes are also present in the lateral ventricles. The 
vessels forming the choroid plexuses and velum interpositum are studded 
with tubercles and besmeared with lymph ; the lateral ventricles are 



47 6 Diseases of the Nervous System 

distended with fluid, while in the majority of cases the parts around, the 
corpus callosum, fornix, and optic thalamus, have undergone white soften- 
ing and may be washed away or ragged out by a stream of water. The 
presence of fluid in excess in the lateral ventricles is due to the inflamma- 
tory processes going on in the choroid plexuses ; this gives rise when in 
excess to dilatation of the ventricles, softening of the surrounding parts, and 
flattening of the convolutions. It was these mechanical effects which so 
struck the older observers like Whytt, who overlooked the presence of 
tubercles as the primary cause, and saw only in such cases an 'acute 
hydrocephalus ' or ' water on the brain.' What further justisfies these older 
observations is that in some cases the amount of lymph is very small and 
tubercles are found with difficulty, while there is much subarachnoid fluid 
as well as distention of the ventricles, and the brain substance is soft and 
cedematous. In a few cases large tracts of the superficial or central parts of 
the brain are softened and diffluent, the brain substance being yellow or 
plum-coloured from the presence of extravasated and altered blood, effects 
due to thrombosis or some disturbed condition of the circulation. A micro- 
scopical examination of hardened portions of the grey matter will show 
tubercles and effusion of leucocytes around the capillary arteries which enter 
the surface of the brain. 

How do the symptoms during life correspond with the appearances 
found after death ? The older writers were probably correct in ascribing 
the excitement during the first stage to the inflammatory engorgement of 
the arterial system of the brain ; the later stages of drowsiness and coma 
to the effusion of fluid into the lateral ventricles, which gradually compressed 
the surrounding parts and interfered with their blood supply ; the hemiplegia, 
paralysis of facial, &c, to the softening which so frequently takes place. The 
retraction of the head and stiffening of the limbs are also due, we are in- 
clined to think, to the pressure exerted on the motor tract by the ventricular 
effusion. 

Other tubercular lesions are constantly found in association with tuber- 
cular meningitis, the commonest of these being caseous mediastinal glands. 
The lungs also are rarely free from tubercle. 

In non-tubercular meningitis the distribution of the lymph, which is often 
purulent, is less exclusively basal, more often being found over -the convex 
surface and between the hemispheres in the longitudinal fissure. In the more 
chronic cases the base of the brain and cerebellum may be adherent to the 
skull, and much fluid may be present in the lateral ventricles. 

Treatment. — The prophylactic treatment of tubercular meningitis is 
much the same as that of tuberculosis generally. All children who are so 
inclined require the most constant care in all the relations of life. Residence 
in cities must be prohibited, and country or seaside life insisted upon. A 
farmhouse where pure milk and cream, &c, may be had, in a bracing but 
not too bleak situation, may be selected as a residence. All book work should 
be stopped, and all forms of excitement be strictly prohibited. The diet 
should be carefully regulated ; fats, if they are found to agree, should be 
taken in fair quantities. 

The child should be warmly clad and carefully protected from changes 
of weather. The bowels, if inclined to be constipated, should be carefully 



Tubercular Meningitis — Simple Meningitis 477 

regulated with hyd. c. cret. or rhubarb and soda. The slightest suspicion 
of cerebral symptoms should be met by putting the child to bed in a darkened 
room, giving a calomel purge, and an exclusively milk diet, with free 
administration of bromides. One or two grains of calomel with some sugar 
may be given, and some saline, such as a quarter or half a seidlitz-powder, 
the following morning. Five to ten grains of bromide of potassium should 
be given every four hours. The vomiting is best treated by purging 
smartly, and giving peptonised milk prepared with Benger's peptonising 
powders, or Savory and Moore's tinned peptonised milk. If persistent 
vomiting follows the ingestion of food, all food must be stopped by the mouth, 
and Brand's extract, or peptonised milk and bromide, given by means of an 
enema. Nothing is gained by continuing to purge after the initial dose of 
calomel has emptied the bowels thoroughly. If there is much cerebral ex- 
citement, larger doses of bromide may be given with the tincture or succus 
hyoscyami. We doubt very much if blisters, setons or leeches are of any 
service in tubercular meningitis, though in simple meningitis, if the excite- 
ment or delirium is severe, a leech applied to the temples will certainly 
relieve. Cold to the head is of undoubted value and in all cases should be 
applied, an ice-bag of india-rubber being used in preference to any other 
form. Leiters tubes form a convenient method of applying cold to the 
head, and they can be used where ice cannot be obtained. Mercury given 
freely in the form of perchloride is of all drugs the one most likely to be of 
service in simple meningitis. Iodide of potassium is frequently prescribed, 
though with doubtful advantage. Drainage of the subarachnoid space in 
cases of acute tubercular meningitis has been carried out by an opening 
made either in the lumbar or cervical spine, or preferably by trephining the 
occipital bone. Successful cases have been recorded, but we have no personal 
experience of the method. Operation if done at all should be performed 
before coma sets in. 

Non-tuberculous or Simple Meningitis. — While tuberculous mening- 
itis is by far the commonest form met with during early life, and overshadows 
all other forms by its importance, yet other forms are also met with which 
require careful consideration. A meningitis occurs at times in association 
with pneumonia, summer diarrhoea, pyaemia, otitis, scarlet fever, and some 
other of the infectious fevers. Presumably in these cases it is infective : 
there is a transference of cocci or other organisms from the lungs, intestinal 
tract, or some other locality to the membranes of the brain, and inflammation 
set up. One form of meningitis, or, rather, cerebro-spinal meningitis, occurs 
in widespread epidemics, though it is comparatively rare in this country. 
Another form which is also due to the presence of a specific organism mostly 
affects the posterior region of the base of the brain. Meningitis in some 
instances appears to be due to exposure to the sun ; in other cases it follows 
an injury, and in some others it is idiopathic, or, in other words, no cause can 
be assigned. In acute septic cases it is mostly purulent. 

Acute Form. — In some cases, both in infants and older children, the 
attack may run a very acute course, death from convulsions taking place in 
two or three days. The acute meningitis in some of these cases is asso- 
ciated with a pleuro-pneumonia or peritonitis. As an instance of rapid 
death from what was probably an acute meningitis, though the post-mortein 



47$ Diseases of the Nervous System 

examination showed no effused lymph, the following case may be taken as 
an example : 

Acute Meningitis. — Beatrice B.,aged 5^ years, was a healthy child till six months ago, 
when she was taken with pain in the head, fever, and vomiting, but recovered in a day or 
two. Two days before admission, when playing in the street, she ran in, complaining of 
pain in the head, and vomited ; she continued to vomit constantly for two days ; she had 
a fit shortly before admission. There had been no injury to the head ; the weather was 
hot at the time (August). On admission she looked ill, her face having an expression of 
anxiety : two hours after admission she was convulsed and died. Her temperature was 
not taken. At the post-mortem all the organs were healthy, the capillaries of the brain 
were intensely injected, and there was much clear fluid in the lateral ventricles ; the 
arachnoid membrane was somewhat opaque. 

In this case microscopical examination showed that the capillaries of the 
meninges and grey matter of the brain were distended and gorged with 
blood, and, though it cannot be certainly assumed that this congestion was 
primary and inflammatory, there is a strong probability that the case was 
one of acute inflammatory congestion of the brain and membranes. Similar 
cases of rapid death from acute hyperaemia of the brain after exposure to a 
hot sun are recorded by Lewis Smith and Soltman. Henoch mentions a 
similar case in a girl of five years, the attack beginning in the same way 
with headache and vomiting, death taking place within forty-eight hours, 
preceded by convulsions and coma. At the post-mortem a purulent exuda- 
tion was present on the convexity and at the base of the brain. 

In the following case meningitis supervened on acute diarrhoea : 

Acute Enteritis, Meningitis. — Annie B., aged 3! years, was seized with vomiting and 
purging (in August) ; the next day, when admitted, she was in semi-collapsed condition. 
A few hours afterwards she lapsed into unconsciousness. She was delirious, and there 
were muscular twitchings. Death took place rather suddenly at the end of the second day 
of the illness. At the post-mortem the pia mater was intensely congested, the arachnoid 
opaque, the Sylvian fissures were glued together with lymph, there were no tubercles ; 
there were patches of congestion in the intestines and commencing pneumonia of the base 
of the right lung. 

These extremely acute cases are exceptional, and a doubt may often 
surround the diagnosis, as acute meningitis in the early stages may with 
difficulty be distinguished from the onset of some zymotic disease,-as scarlet 
fever or influenza, or perhaps more likely of pneumonia ; and if the course 
terminates early in a convulsion it may be impossible even at the post- 
mortem to say with certainty what has been the exact nature of the case. 
Death from a convulsion, accompanied by spasm of the glottis, gives 
rise to a mechanical engorgement of both lungs and brain, and caution is 
required in positively asserting that an early meningitis or pneumonia is 
present. 

In the majority of cases acute meningitis runs a course of a week or ten 
days, the symptoms resembling those described under tubercular meningitis. 
There maybe a history of an injury, or of a past otitis, or of exposure to the 
sun, or there is an empyema, pleurisy, or erysipelas. The early symptoms 
are those of intense headache, with injection of the conjunctivae, vomiting, 
delirium, strabismus, and often high fever, perhaps as high as 103 to 105 . 
Later, the pulse becomes slow and hesitating, the abdomen is retracted, the 



Posterior Basal Meningitis 479 

cervical muscles are rigid, and Cheyne-Stokes respiration, coma, and various 
paralyses ensue. At the post-mortem a more or less intense, perhaps puru- 
lent, meningitis is found affecting the convexity and base of the brain. 
Pneumococci or other organisms are present in the lymph or inflammatory 
exudations. 

Posterior Basal Meningitis. — Basal meningitis is for the most part 
tuberculous, but there is a well-marked non-tuberculous form which is 
limited pretty much to the neighbourhood of the pons, medulla and cere- 
bellum, and interpeduncular space. The inflammation is subacute or 
chronic, adhesions form between the parts gluing them together, the fourth 
ventricle becomes obliterated, and internal hydrocephalus takes place from 
blocking of the aqueduct of Sylvius, if the patient lives long enough. Infants 
are usually the chief sufferers, but older children are sometimes affected. 
The most prominent and often the earliest symptom is cervical opisthotonos ; 
this varies from time to time, the muscles of the neck being sometimes 
relaxed ; at other times they are so rigidly and completely contracted that 
the neck is bent and fixed at right angles to the trunk. The rigidity is not 
confined to the cervical muscles, but the muscles of the back and lower 
limbs are in a state of spasm, so that the opisthotonos is general. Vomiting 
and convulsions are often present in the early stages. Drowsiness and fever 
are mostly present. Squint or nystagmus may occur, often there is impaired 
or complete loss of vision, optic neuritis is absent. There may be 
retraction of the abdomen, but this is not so constant as in tuberculous 
meningitis. The bowels are often loose or normal. The course of the 
disease is chronic, lasting six weeks or three or four months, though the 
patient may be cut off before this. In the later stages — that is, if the patient 
survives — enlargement of the head takes place, as the result of an internal 
hydrocephalus caused by the adhesions formed at the base of the brain. 
There may be hyperpyrexia, as in the case related below, before death. 
While these cases are usually fatal, they are by no means always so. As we 
have said, infants are most often attacked, but we have seen similar cases in 
children of three or four years of age which have ended in complete recovery. 
There has been hyperpyrexia, drowsiness, extreme opisthotonos, the 
symptoms lasting for a week or ten days and then gradually disappearing. 

As already stated, the post-mortem findings in these cases include lymph 
or fibroid adhesionSj according to the stage in which death has taken place 
matting together the interpeduncular space, pons, medulla, base of the 
cerebellum, fourth ventricle, and internal hydrocephalus. Dr. G. F. Still 
has shown that a specific organism is present in these cases ; a diplococcus, 
which grows readily on agar, is stained by methylene blue, but not by Gram's 
method. It differs in many respects from the pneumococcus and the 
diplococcus of cerebro-spinal meningitis. 

The following case may be taken as an instance : 

Basal Meningitis, Hydrocephalus. — E. P., aged 7 months ; no history of syphilis. At 
6 weeks of age had an attack, during which he was always crying and throwing his head 
back. A month ago he became drowsy and dull, and had twitchings of right arm and leg. 
He is unable to see. Admitted June 13. Constant vomiting ; abdomen retracted ; limbs 
rigid ; toes point ; fingers are flexed. From June 13 to June 25, when he died, he was 
comatose ; there was remarkable hyperpyrexia ; the temperature rising on succeeding 



480 Diseases of the Nervous System 

days toio<5° F. ( io8-6°, T07 , 107-4°. and 107-8° before death. Post-mortem showed lymph 
mostly confined to the interpeduncular space, pons, and base of cerebellum. Both 
ventricles contained fluid and lymph ; cortex thinned to about \ inch in thickness from 
internal pressure. 

A subacute basal meningitis may occur in older children, and recovery 
from such attacks apparently takes place. Thus in a case of our own — that 
of a boy who died suddenly, in apparent health, and on whom a coroner's 
inquest was held — an acute hydrocephalus was present, with some adhesions 
between the base of the brain and the skull, apparently the remains of a 
meningitis from which there was a history of the boy having suffered some 
months before. 

As an example of a simple subacute meningitis following an injury, the 
following case of Dr. Hutton's may be given : 

Basal Me?iingitis, Hydrocephalus. — William C. , aged 8 years, fell into a cellar, striking 
the back of his head, some three months before admission. He vomited off and on for 
a day or two, but did not lie up ; he suffered from pain in the back of his head almost 
constantly after the fall. He was admitted with squint and pupils of unequal size ; he 
had convulsions, optic neuritis, and lapsed into a semi-comatose state with Cheyne-Stokes 
respiration. He died twenty-four days after admission. At the post-mortem the dura 
mater was thickened and congested, there was much lymph at the base and between the 
hemispheres, and also between the latter and the cerebellum ; the lateral ventricles were 
much dilated and distended with serum. There were no tubercles anywhere. 

The following case illustrates the association of subacute meningitis and 
hydrocephalus with pneumonia : 

Basal Meningitis, Hydrocephalus, Chronic Pnezimonia. — B. V. R., aged 5 years, was 
always a healthy girl till seven weeks before admission, when she had an attack of feverish- 
ness and vomiting ; she has vomited more or less ever since ; she has also been losing 
flesh. On admission she was drowsy and irritable ; screaming when disturbed with a 
shrill cry ; the head was thrown back, the neck retracted ; there was no optic neuritis. A 
few days after she had two fits. She continued to vomit at frequent intervals. There was 
much rigidity of the muscles of the neck, with the head thrown back ; the hands and arms 
remained normal, while the hips and knees were flexed and the abdomen retracted. 
Later she suffered from double pneumonia at the bases, she wasted more and more, 
gradually became unconscious, and died ten or eleven weeks from the commencement of 
her illness. An examination of the brain showed that the Sylvian fissures were matted 
together with fibroid adhesions ; similar adhesions were present in interpeduncular space 
and surrounding the third and fourth nerves ; fibroid adhesions were also present on the 
upper surface of the cerebellum. The lateral ventricles were much dilated and distended 
with fluid ; there had also been an inflammatory condition of their lining membrane, with 
exudation of fibrin. There was no tubercle anywhere ; there was a double pneumonia 
becoming caseous. 

It is very probable that the last three cases related were not examples of 
the posterior basal meningitis of infants just described — at any rate, were not 
caused by the same micro-organism. Our knowledge is still imperfect re- 
specting the bacteriology of meningitis. 

Epidemic Cerebro-spinal Meningitis. — Meningitis occurs in some 
countries in epidemics, and is usually accompanied by inflammation of the 
membranes of the cord ; sporadic cases, however, occur. Limited outbreaks 
have occurred in Dublin and Glasgow, but such are rare in this country. 
Both adults and children are attacked. The symptoms of cerebro-spinal 



Epidemic Cerebrospinal Meningitis 481 

meningitis in infants closely resemble those of simple meningitis, but 
usually there is more marked rigidity of the cervical muscles and muscles of 
the spine, the legs may be rigid and drawn up, and there may be more or 
less rigidity about the muscles of the arm and forearm. Sometimes there 
is opisthotonos resembling tetanus. In older children pain in the back and 
limbs may be complained of, being more especially referred to the back of 
the neck or sacrum ; sharp shooting pains may be complained of in the 
limbs. There may also be general hyperesthesia. In the epidemic foim 
purpura and herpetic eruptions are common. Pneumonia is a common 
complication. Weichselbaum has described a diplococcus, the D. intercellu- 
laris which he believes to be the specific cause of epidemic cerebro-spinal 
meningitis. The diagnosis between cerebral meningitis and a cerebro- 
spinal meningitis in infants is very difficult, often impossible, as it is difficult 
to localise pain and to arrive at a conclusion as regards a general hyper- 
esthesia. Retraction of the head and more or less rigidity in the limbs may 
be present in both, but they are most marked when the spinal meninges are 
affected. Both tetanus and tetany may be mistaken for it ; in the former 
there is marked trismus before the onset of the opisthotonos, and the 
temperature is normal or only slightly raised ; and in the latter the peculiar 
spasm of the muscles of the hands and feet, and normal temperature, suffice 
to distinguish the two diseases. Blindness may result from optic neuritis, 
and deafness from inflammation of the auditory nerve. The child may 
recover its health completely, but is blind and deaf. Hydrocephalus may 
also take place. The child may suffer from imbecility. 

latent Form. — Meningitis, like peritonitis and pleurisy, may be present 
without giving rise to any very definite cerebral symptoms ; this is especially 
so when it occurs secondarily, and the symptoms to which it gives rise may 
be overshadowed by the primary disease. It may occur in association with 
acute pneumonia or peritonitis, or acute intestinal catarrh, without its pre- 
sence being suspected, partly because the headache, delirium, and fever are 
naturally attributed to the more obvious disease present, and there is neces- 
sarily a difficulty in unravelling the complex association of symptoms and 
referring each to its cause. In some few instances a meningitis may exist 
without there being any cerebral symptoms whatever, as in the following- 
case : 

Purulent Meningitis. — An emaciated child (boy) of 4 years of age, who had recently 
suffered from whooping cough, was admitted to hospital with some dulness at the base of 
one lung. There was a history of diarrhoea, and during the fortnight preceding his death 
he had five or six diarrhceal stools daily. There was a hectic temperature, no vomiting, 
headache, or optic neuritis ; he was perfectly intelligent, and died apparently of exhaustion. 
It was supposed that there was general tuberculosis. At the post-mortem the lungs were 
found adherent to the diaphragm ; some inspissated pus was found present at the left 
base, evidently the remains of a small empyema ; there were no tubercles anywhere. 
There was some purulent lymph covering the inner surface of the dura mater, the convex 
surface of the brain, and the vessels in the transverse fissure, and bathing the surfaces of 
the lateral ventricles ; the base of the brain was matted with lymph. There was clear 
fluid in both tympanic cavities, but no pus. 

It is in wasted, anaemic children that such lesions as purulent men- 
ingitis, pleurisy, or peritonitis may exist without giving rise to marked 
symptoms. 

I 1 



482 



Diseases of the X croons System 



Treatment. — The treatment of cases of non-tuberculous meningitis is 
very much the same as that already given. Unfortunately medicines can 
do but little. In the more chronic cases, blisters and iodide of potassium in 
large doses are worth trying. Ergot has also been given. Morphia, chloral, 
bromide may be necessary to relieve pain and sleeplessness. 



Chronic ZHening-o-encephalitis. Pachymeningitis 

Chronic Meningitis. — A chronic inflammatory process, affecting more 
especially the convex surface of the brain, occurs occasionally during 
infancy, apparently also during intra-uterine life. In such cases the 
surface of the brain becomes adherent to the dura mater, a thickening of 
the membranes taking place resembling the pachymeningitis of adults. A 
membranous exudation may be thrown out, and blood may be effused. Carr 
has recorded 1 a case of this sort in an undoubted syphilitic child of nineteen 
months. It had suffered from repeated convulsions and was idiotic. At the 
post-mortem there was no hydrocephalus, the dura mater was lined by a 

membrane of a gelatinous appear- 
ance, the same gelatinous material 
covered the cortex and base. The 
brain weighed 18 oz., there were 
some areas of sclerosis bordering 
on the fissure of Sylvius. Such a 
condition may be associated with 
a chronic hydrocephalus. The 
symptoms present are frequently 
not distinctive, or they may be 
simply those of chronic hydro- 
cephalus ; there may be defective 
intelligence or idiocy, probably 
also convulsions ; retraction of the 
head and rigidity and flexion of 
the limbs are likely to be present if the child lives any length of time. The 
etiology of such cases is doubtful : they are always suggestive of hereditary 
syphilis. As chronic hydrocephalus is often associated with the meningitis, 
a diagnosis of hydrocephalus is probably all that can be made during life. 

A meningitis during intra-uterine life, by interfering with the growth and 
development of the brain, may produce various results, such as hydrocephalus, 
sclerosis, or an abnormally small brain. Thus in a case 2 of Dr. T. Barlow's, 
in an infant dying at seven weeks of age, the head measured only 10^ inches 
round, and the brain weighed only 9 drachms ; the convolutions were 
hardly recognisable over the greater part of the convexity, and the pia 
mater and cortex beneath it were invaded with calcareous plates ; the 
choroid plexuses of the lateral ventricles were also partially calcified. In 
this case there seems to have been an intra-uterine meningitis, followed by 
calcification of the effused lymph and some atrophy of the subjacent brain 
tissue. In the following case there had been apparently a meningo- 




Fig. 96. — Microcephalic infant. Syphilitic infant 
four weeks old. (See case.) From a photograph 
by Mr. J. Hepworth. 



1 Lancet, January 1895, p. 154. 



2 Path. Trans, vol. xxxviii. 



CI ironic Meningitis 



encephalitis occurring 
was syphilitic. 



483 

during fcetal life giving rise to sclerosis ; the infant 



The father of the infant suffered from sore throat, rash, and serpiginous ulceration of 
his legs. The mother, when pregnant, suffered from sore throat, and has had a squamous 
syphilide on her face ; an infant born subsequently to the patient suffered from coryza and 
eclampsia. The infant was first seen when two weeks old : it was microcephalic, its head 
measuring loh inches in circumference (see fig. 96), it suffered from coryza and eclampsia. 
It was idiotic, being unable to recognise anything. The fits continued, both arms and legs 
became paretic and later spastic. It died at five months of age. The brain weighed -x\ oz. 
(after having been in weak spirit). There was excess of subarachnoid fluid, the arachnoid 
was milky, there was no recent lymph, but at the base of the brain there was some yellow 
detritus. The convolutions in the Sylvian fissure and neighbourhood had mostly disap- 




Fig. 97. —Brain of infant (fig. 96), showing irregular nodulation of surface from 
meningo-encephalitis. From a photograph by Mr. J. Hepworth. 

peared, the surface of the brain being irregular and nodular. There was a depressed scar- 
ring over both frontal lobes (see fig. 97). There had been a meningitis of the choroid 
plexus and hydrocephalus. No endarteritis was found. 

In the following case, which lived to be twenty months old, the sclerosis 
on the surface of the brain was well marked : ' 



Festal Meningo-encephalitis. — A child who died at the age of twenty months had been 
a complete idiot from his birth, and had suffered from convulsions ; he was blind and cleaf ; 
the legs and arms were drawn up and stiff. At the post-mortem the brain was found hard 
and shrunken over the convex surface ; the convolutions had completely disappeared, the 
surface being simply grooved by the vessels and granular like a ' cirrhosed ' liver ; at the 
base and median surfaces the convolutions were fairly well marked. The pia mater con- 
sisted of many tortuous vessels, which could be dissected off. On vertical section it was 
.seen that the grey matter and white matter also were hard and shrunken, and hardly 

1 1 2 



4 8 4 



Diseases of the Nervous System 



distinguishable from one another. Microscopical examination showed an increase of con- 
nective tissue and an absence of nerve elements. There was descending ■ tion in 
the pons and cord (see fig. 98). 

Endarteritis. Softening-. — An acute arteritis in rare instances occurs in 
infants a few months old who are the subjects of congenital syphilis. Such 
cases have been recorded by Dr. T. Barlow, Chiari, and Heubner. 

In infants, the principal symptoms are convulsions, in the form of 
muscular twitchings of an arm or leg, followed by paresis and contractures. 
The infant gradually becomes idiotic. The chief changes are in the arteries 
as described by Heubner : there is a thickening of the internal coat, the 
nuclei between the endothelium and the fenestrated membrane becomin<'' 




Fig. 98. — Sclerosis of Brain. From a boy of twenty months. The convolutions have dis- 
appeared, the surface of the brain resembling a hob-nail liver (probably syphilitic). The 
openings which transmitted the meningo-cephalic vessels appear as black points. 



increased in number, to be followed by fatty changes ; thrombosis takes 
place at the seat of the inflammatory changes. Softening of the brain 
follows over the area supplied by the blocked arteries. The following case 
illustrates this : 

Syphilitic Arteritis. Softening. — Infant first seen at three months of age, when suffer- 
ing from coryza and a well-marked rash. A month later the epiphyses of the lower end 
of the tibia and fibula, also the lower ends of the radius and ulna, were swollen and tender 
(fig. 93 was drawn from this case). When seven months old he began to suffer from con- 
vulsions, mostly left-sided at first, later the convulsive movements became general. In the 
course of a few months the left arm and leg, which were more or less paralysed, began to 
draw up and become more or less rigid ; the elbow was bent at right angles, the arm pro- 
nated, and the fingers flexed ; still later the right arm became similarly affected ; the child 
gradually became idiotic, and died at four months old. It was under mercurial treatment 
from three months of age. At the post-mortem the arachnoid was of a milky colour, and 
there was an excess of subarachnoid fluid ; there was no effused lymph or meningitis. 
The superficial layer of the grey matter on the convex surface of both hemispheres, 
especially the right, was softened and could be readily scraped away ; the superficial 
layer of the caudate nucleus and optic thalamus were in the same condition of softening. 
Microscopically, the grey matter showed extensive fatty degeneration ; the minute arteries 
were extensively blocked with old thrombi, their inner coats being thickened and their 



Pachymeningitis — Acute Hydrocephalus 485 

nuclei increased in number. The large arteries were normal, as far as could be made out. 
There seems to have been an extensive syphilitic arteritis of the small meningo-encephalic 
arteries, thrombosis, and secondary softening of the superficial grey matter. 

Pachymeningitis, with thickening" of the dura mater and adhesions 
to the brain and skull, with wasted convolutions of the brain and endarteritis, 
are found in cases of syphilitic dementia (see p. 454). The paresis and 
dementia commence shortly before puberty ; there is usually more or less 
blindness from disseminated choroiditis and deafness. The course is very 
chronic. 

Hydrocephalus 

Acute Hydrocephalus occurs only in association with an acute men- 
ingitis. In the majority of cases of acute meningitis, whether tuberculous or 
simple, there is an excess of fluid in the lateral ventricles, the result of an 
intra-ventricular meningitis, and a consequent excessive exudation from the 
vessels of the choroid plexus. In exceptional cases the meningitis is con- 
fined to the ventricles. In those rare cases where an acute or subacute 
meningitis ends in recovery a chronic hydrocephalus may be left ; in these 
cases the head slowly enlarges in succession to the symptoms of a meningitis. 
Excess of fluid may be found in the subarachnoid space in acute meningitis. 

Chronic Hydrocephalus. — The accumulation of an excess of fluid in 
the ventricles of the brain is by no means an uncommon condition in infants 
and children . ( 1 ) It may be congenital, the accumulation taking place before 
birth, and it may give rise to difficulty in the extraction of the head. (2) It 
may follow an acute meningitis or subacute meningitis. (3) It may arise 
without any apparent cause. (4) It may be the result of a tumour, as for 
instance a tumour of the cerebellum, compressing the veins of Galen, and in 
other ways interfering with the circulation. 

In the majority of cases the child is born healthy, and the enlargement 
of the head is first noticed when the infant is a few weeks to a few months 
old ; usually no cause can be assigned, but some of the cases are syphilitic, 
and it is not improbable that syphilis plays an important part in the pro- 
duction of hydrocephalus. Enlargement of the head is preceded in a few 
cases by distinct cerebral symptoms, as convulsions, fever, drowsiness, and 
retraction of the head, so as to suggest the probability of the meningitis 
perhaps being local rather than general. As the fluid accumulates in 
the ventricles the head enlarges, the bones forming the vault of the cranium 
become thinned and open out, so that the fontanelles are enlarged and the 
edges of the bones at the sutures are separated from one another (see fig. 99). 
The fontanelles are bulged and have a fluctuating feel, the occipital and 
parietal bones maybe so thin that moderate pressure with the finger is suffi- 
cient to bulge them in. The cranium assumes a spherical form, and its 
increased size contrasts with the child's face, which may be thin and sunken, 
giving the child a characteristic appearance. The forehead is rounded, 
and projects so as to overhang the face ; the parietal and occipital bones 
assume a similar shape, so that the head has a globular or rounded form. 
There may be nystagmus. The general rounded contour is broken by the 
prominence of the frontal and parietal eminences ; at these spots the bone 



486 



Diseases of the Nervous System 



is thick and solid, and consequently cannot be bulged out like the thinner 
bone elsewhere. The skin of the forehead and scalp is thin and shiny from 
being stretched, and the cutaneous veins are distended, especially when the 
infant cries ; the eyes project : their axes may be divergent, and there may- 
be difficulty in closing the eyelids. The infant cannot raise its head, and if 
propped up the head rolls over in a helpless sort of way. The condition of 
the intellect varies considerably ; in the majority of cases, where the hydro- 
cephalus is moderate in degree, the intellectual powers are surprisingly good 
when it is considered what amount of compression and flattening out the 
grey matter on the surface of the brain is exposed to by the accumulation of 





Fig. 99. — Outline of Head in Chronic Hydrocephah 
a a, frontal bones ; b b, parietal bones. 



fluid in the lateral ventricles. In extreme cases there is certain to be marked 
intellectual defect, perhaps amounting to idiocy. The limbs are mostly 
paretic, and the lower extremities especially are rigid, and flexed upon the 
abdomen ; permanent contractures are apt to follow, a result probably due 
to compression of the pons. Atrophy of the optic nerves may take place 
from compression or stretching of the optic tracts or commissure. The 
course of the disease is usually chronic, and infants will live for months or 
even years, but ordinarily they gradually waste and die. The child shown 
in fig. 100, who was 6^ years of age, had suffered from chronic hydrocephalus 
since three months old ; he was well nourished ; his head measured 
31 \ inches in circumference ; he was a complete idiot. The legs were bent 



Chronic Hydrocephalus 



487 



at the knee and flexed on the abdomen, but the spasm of the muscles varied 
from time to time ; the hands were kept closed, and the elbows were flexed 
and more or less rigid. We have known recovery to take place, even after 
rigidity of the legs has come on. 

In older children, when the disease comes on after the closure of the fon- 
tanelles, the head enlarges more gradually, thinning the bones and even open- 
ing up the fontanelles and sutures ; in these cases the hydrocephalus is mostly 
due to a cerebellar tumour ; blindness and imbecility gradually supervene. 

Diagnosis. — This is not difficult when the disease is well advanced ; 
difficulty, however, occurs in the early stages when the accumulation of fluid 
is small, and when hydrocephalus may be mistaken for a rickety skull, or 
simply a large head without distension of the lateral ventricles such as occurs 
in rickets. The friends of patients often ask whether a child who has a large 
head has ' water on the brain.' A 
diagnosis can only be made when 
the head enlarges under observa- 
tion, the bones becoming thinned, 
the fontanelles bulged and fluctu- 
ating" ; the globular shape which 
it assumes distinguishes it from 
the misshapen head of a typical 
case of rickets with the prominent 
eminences, flattened vertex, and 
thick edges of the bones. In the 
simply enlarged head, from the 
presence of an abnormally enlarged 
brain, there is no opening out and 
bulging at the fontanelles, nor 
usually any evidence of a thin 
skull. 

Morbid Anatomy. — In those 
cases in which the excessive quan- 
tity of fluid in the ventricles is 
caused by a cerebellar tumour 
the mechanism is tolerably clear, 

for any stretching of the tentorium cerebelli must compress the straight 
sinus which runs -along at the base of the falx cerebri, and consequently 
check the onward flow of blood in the veins of Galen and inferior longitudinal 
sinus. As the veins of Galen return the blood of the choroid plexus, it is 
easy to understand how a chronic hydrocephalus may be thus produced. 
In these cases the lateral ventricles are distended with a clear fluid of low 
specific gravity, the third and fourth ventricles join in the dilatation, and the 
iter is also enlarged. In another class of case which occurs after a basal 
meningitis (seep. 479), it is clear that the adhesions which form in the neigh- 
bourhood of the fourth ventricle have the effect of sealing up the communica- 
tion between the lateral ventricles and the subdural space by closing the 
aqueduct of Sylvius and transverse fissure. There is no escape for the fluid 
secreted in the lateral ventricles, and it is consequently ponded up and 
gradually distends the ventricles as it increases. In those cases which form 




100. — Chronic Hydrocephalus in a boy aged 
6j years. 



488 Diseases of the Nervous System 

the majority, where no tumour is present, and no evidence of a past or present 
meningitis, the mechanism of the hydrocephalus is by no means clear. In 
these cases the lateral ventricles and their horns may be enormoush dilated, 
the grey matter on the surface is flattened out and reduced in some cases to 
the thickness of cardboard, the convolutions being lost or only traced with 
difficulty. The contained fluid is clear, of specific gravity about 1005, with 
a small quantity of albumen and salts ; the third and fourth ventricles are 
dilated ; the pons is often flattened by the pressure of fluid in the fourth 
ventricle. In these cases, where there is no apparent obstacle to the escape 
of the fluid from the ventricles, no satisfactory explanation of the hydro- 
cephalus is forthcoming. In some cases at least there may be some inflam- 
matory condition of the choroid plexuses, but as a rule the lining membrane of 
the ventricles and choroid plexuses are healthy to the naked eye. It would 
appear that for some unknown reason there is an excessive secretion of 
cerebro-spinal fluid. 

Treatment. — The treatment of chronic hydrocephalus when once esta- 
blished is unfortunately unsatisfactory, and but little can be done to influence 
the progress of the disease. In any case in which there is reason to suspect 
syphilis some mercury should be given internally, and some ung. hydrarg. 
applied to the head ; or strips of mercury plaister may be used to effect a 
moderate compression and aid the absorption of the drug. Some cases in 
infants appear to be benefited by this treatment ; but, presuming there is a 
chronic syphilitic meningitis, it is by no means certain to be influenced 
by anti-syphilitic treatment. Both mercury and iodides should be tried, 
especially as there is no other drug which affords any chance of success. 
Some success has been claimed for compression of the head by means of 
strips of plaister or an elastic bandage ; if it is decided to try this method 
its risks must be borne in mind. The circulation through the scalp is 
interfered with by its compression between the skull and bandage, the 
brain is also compressed between the skull and the fluid in the ventricles. 
We have seen extensive sloughing of the scalp in a case of hydrocephalus, 
the result of a too tightly applied elastic bandage. Xo real compression can 
be of any service, and is decidedly risky ; but a lightly applied bandage may 
be of use as a support. Puncture with one of Southey's cannulas through 
the anterior fontanelle, avoiding the superior longitudinal sinus, offers more 
chance of at least temporary relief. It is usually harmless, though if too 
much be withdrawn there is a risk of collapse of the brain substance, with 
perhaps convulsions and sudden death. We have frequently drawn off as 
much as 12 oz. through one of Souther's cannula?, but the fluid reaccumulates 
•in a few days. In some recorded cases a rapid rise of temperature and 
sudden death took place when the lateral ventricles were quickly emptied 
(Sutherland). 

Of other methods of treatment we have had no experience. Pott has 
treated chronic hydrocephalus by incision and drainage, and Ranke by 
puncture and injection of tincture of iodine (10 grms. diluted with 20grms. of 
water). It cannot be said with much success. More recently Sutherland 
and Watson Cheyne have devised a method of draining the over-distended 
lateral ventricles into the subdural space by means of a bundle of fine catgut. 
The catgut drain is so arranged that one end projects into the ventricle, the 



Hypertrophy and Atrophy of the Brain 489 

other end into the subdural space. The w ound in the dura mater and skin 
necessary to insert the drain is then sutured up. In the cases operated on 
the fluid gradually diminished as the ventricle drained, but in one case a 
second operation was necessary to drain the other ventricle. It is possible 
that this operation may be of use in cases of chronic hydrocephalus follow- 
ing basal meningitis. 1 

Hypertrophy of the Brain. — Rickety children often have abnormally 
large heads, a condition which is frequently attributed to ' water on the 
brain.' In reality such abnormally large heads are not hydrocephalic, 
their increased size being due in some cases to the prominent frontal and 
parietal eminences, but more often to an enlarged brain. The cause of this 
hypertrophy is not known, and the nature of the enlargement in the brain, 
liver, or spleen, which is apt to take place in rickets, is not clearly under- 
stood. In several cases coming under notice of children in their second and 
third years, with large heads, who have had rickets in a severe form and who 
have died in convulsions, the brains have been large, the convolutions well 
marked, the brain substance fairly firm, and the microscopical examinations 
revealed no change that we could detect. Such brains are usually very vas- 
cular, but, as death often takes place through convulsions, it is hardly safe to 
assert that the vascularity is anything more than a secondary effect, result- 
ing from the manner of death. In some cases the increase in size has been 
attributed to an increase of the connecting elements, the neuroglia, but it is 
needless to say it is a very difficult matter to decide if this is so in a brain 
in which the enlargement is general ; in our own cases, certainly, there was 
no striking change. It is certain that enlargement of the brain in these 
cases is not accompanied by any precocity of intellect ; indeed, it is rather the 
reverse, as such children are mostly backward, not only in physical, but also 
in mental development. If the quantity of brain matter is large, the quality 
is certainly poor. 

Atrophy of the Brain. — The brain may be of abnormally small size, 
and yet the brain substance normal ; in such cases there is usually more or 
less mental defect. 

In some cases of children who have suffered from chronic wasting 
secondary to gastro-intestinal atrophy, during the last few weeks of life the 
lower limbs become more or less flexed and rigid and the abdomen some- 
what retracted. At the post-mortem the cerebral hemispheres are partially 
shrunken and an excessive quantity of fluid is present in the subdural and 
subarachnoid spaces. Presumably this atrophy is secondary to malnutrition 
the result of failure of the digestive powers. 

In the following curious case, atrophy or shrinking of one half of the brain 
appeared to follow a fall on the head : 

Atrophy of a Cerebral Hemisphere.— Bernard. H., sixteen months, admitted to the 
Children's Hospital, April 1893. The mother states the boy was perfectly healthy, and had 
the use of his limbs up to fourteen weeks ago, when he accidentally fell off a table, striking 
the left side of his forehead on the floor. He was picked up unconscious, and remained 



1 For details of the operation see Brit. Med. Journal, Oct. 15, 1898 ; and Clinical Soc. 
Trans, vol. xxxi. 



49Q 



Diseases of the Nervous System 



so for three hours; on consciousness returning he was convulsed. The next day he was 
again convulsed and again became unconscious, in which condition he remained for three 
weeks. At the end of this time he regained consciousness, and it was found that his 
right side was paralysed. On admission he was a well-nourished child, his skull was well 
shaped and symmetrical, his right arm and leg were in a condition of spastic pari 
resisting any attempt to extend them ; there was no squint, but slight nystagmus. He 
was very fretful and not intelligent. As it was supposed there was a clot of blood com- 
pressing the left hemisphere it was decided to explore. On trephining the dura was 
purplish in colour and partially calcified on dividing it ; much clear fluid escaped ; there 
was evidently an enlarged subdural space. The child sank twenty-four hours after the 
operation. At the post-mortem it was noted both sides of the skull were symmetrical, the 



m0 '\x0f 




Fig. 



-Showing Atrophy of left side of the Cerebrum. The right lobe 
the cerebellum is slightly smaller than the left. 



left hemisphere was much smaller than the right (see figs. 101 and 102), the right side of 
the cerebellum slightly smaller than the left. There was no trace of a past meningitis 
or haemorrhage, and no thrombosis or embolism. The convolutions on the left hemisphere 
were wasted, but not markedly so, the pia mater peeled off readily ; vertical sections, after 
hardening in Miiller's fluid, showed there had been a general shrinking of the left hemi- 
sphere, or, at any rate, all parts were proportionately smaller than the right ; there was 
some hypertrophy of the right side. Microscopical examination showed there had been a 
chronic inflammatory induration of the left hemisphere. It was suggested that the case was 
really congenital, the history being misleading ; against this view, however, is the fact that 
the skull was symmetrical and was no smaller on the left side than the right ; and the 
mother was very positive with regard to his being quite well up to the time of the accident. 
He had not suffered from convulsions previously to the fall. 



Tumours of the Brain 



491 



Tumours of the Brain 

While cerebral tumours are by no means uncommon during childhood, 
the different varieties found are few. In the vast majority of cases the tumour 
or tumours consist of caseous masses formed by a local tubercular process. 
These tubercular masses especially have a marked predilection for the 
cerebellum, but are found also comparatively frequently in the pons, basal 
ganglia, and cerebral hemispheres, both on the surface and in the connecting 
white substance. Cysts of uncertain origin are also found, especially in the 
cerebellum. The pons seems the favourite seat of gliomas when they occur. 
Other new growths, such as epithelial carcinomata, may be occasionally 
found growing from the choroid plexus or pia mater. Periosteal sarcomata 
growing from the bone are not uncommon, compressing the grey matter. 
No age is exempt ; tubercular tumours have been found in infants a few 
months old, though they are more common somewhat later. Demme found 
a cheesy mass in the cerebellum of a newly born child, so that tumours may 



B 




Fig. 102.— Transverse Section of Brain shown in fig. 101. The space between the left side 
of the cerebrum and the dura mater, shown by dotted line, contained fluid. 



form during intra-uterine life. Little is known as to the cause which de- 
termines the growth in the brain or its coverings ; it appears certain, how- 
ever, that an injury acts as an exciting cause. A fall or blow on the head is 
followed in the course of a few weeks or months by cerebral symptoms. On 
the fatal termination a cheesy tumour is found in the cerebellum. How the 
injury can have given rise to this can only be surmised ; possibly there is a 
local bruising and punctiform haemorrhage. The most common tumour to 
follow a blow is a tubercular tumour, but then tubercular tumours are vastly 
more common than any others ; nevertheless a cyst or a syphiloma or a 
periosteal sarcoma does appear to follow a blow at times. 

Symptoms. — The getteral symptoms include : (1) persistent headache ; 
(2) paroxysmal vomiting ; (3) optic neuritis ; (4) convulsions. The local sym- 
ptoms are those caused by the tumour interfering with the function of some 
region, and causing some local paralysis or spasm, or incoordination of move- 
ments, or pressure on some venous channel and consequent disturbance of 
the circulation. 

Headache is almost constantly present, though in young children, who are 
unable to complain or describe their feelings, its presence or absence cannot 



49 2 Diseases of the Nervous System 

be determined. Its locality may help to indicate the seat of the lesion, 
but for this purpose it is an uncertain guide ; it may be either frontal or 
occipital in tumours of the cerebellum, and it may shift about from time to 
time, but if fixed and constant at one spot it is of some value for localisation. 
It is usually tolerably constant, or net absent for long together, but is apt to 
be much worse at some times than others. It is mostly made worse by move- 
ment, and when the child is up and about, and is better when it is at rest and 
lying down. Percussion over the seat of the headache usually makes it 
worse or gives acute pain, but it is seldom of any diagnostic value in 
children. The headaches most likely to be mistaken for those due to a tumour 
are the hysteroid headaches, which are often very persistent and severe. 

Vomiting'is a frequent and very characteristic symptom, and maybe present 
in tumours of all parts of the brain, especially of the cerebellum, pons, and 
medulla, and when the root of the pneumo-gastric is involved. The vomiting 
usually comes on suddenly without warning, and without much nausea, and 
may be repeated daily or several times a week without any cause being de- 
tected : such vomiting is very suggestive of cerebral disease, though it must 
not be forgotten that hysterical vomiting also occurs, especially in girls about 
puberty. There may be nausea and constant sickness, with much retching, 
in the later stages of a cerebral tumour. It is often paroxysmal, coming on 
and lasting for several days continuously, being not amenable to treatment, 
and then suddenly improving. 

Optic neuritis occurs in the majority of cases sooner or later, and is 
especially common in tumours of the cerebellum, less so in those of the frontal 
regions. The discs become swollen, so that on examination the edges appear 
at first blurred, and then all distinction between the edges of the disc and 
retina is lost, even to the direct method of examination. The veins become 
distended and tortuous, and haemorrhages occur ; finally, after some months, 
the discs gradually pass into a condition of atrophy. The exact cause of 
optic neuritis is uncertain ■ it occurs in association with tumours in all parts 
of the brain, but may be absent from first to last ; it has been known to occur 
in otitis and in disease of the cord without any discoverable cerebral lesion. 
In a case of our own of acute otitis, there was optic neuritis, and no lesion of 
the brain was discovered post mortem. The neuritis appears to be in some 
cases a descending one, passing along the sheath of the optic tract and pro- 
ducing an intense inflammation at the papilla ; but this can hardly be the 
case often : it is much more likely to be a reflex inflammation, such as herpes 
facialis, which so often appears on the lips and face in inflammatory con- 
ditions of the respiratory tract. Optic neuritis, it is important to remember, 
may occur without any loss of sight, though as atrophy sets in the sight is 
certain to be damaged. It is often of great diagnostic importance, its presence 
being of much value as an indication of a cerebral lesion, though its absence 
in any given case where other symptoms point to some cerebral lesion does 
not necessarily negative the diagnosis. Optic neuritis may come on either 
early or late in the disease. 

Giddiness is often complained of, most commonly in disease of the cere- 
bellum and pons. 

Convulsions. — The first symptom may be a convulsion, which may never 
be repeated, or convulsions maybe frequent during the course of the disease, 



Tumours of the Cerebellum 493 

and may occur in the case of tumours of any part, but more especially when 
the growth involves or compresses the motor cortical centres than when the 
cerebellum is involved. Such convulsions may be epileptiform, but without 
aura. In these cases the nature of the aura and the commencement of the 
fits in some special part afford an indication of the seat of the tumour which 
is situated in the cortex. The convulsions, which commence in one part, 
may quickly become general. 

Paralysis. — The various paralyses and other local symptoms will be 
referred to later on under the regional symptoms. 

Tumours of the Cerebellum. — One of the common seats for a cheesy 
mass is in the lateral lobes of the cerebellum. It is not uncommon to find 
these masses varying in size from a pea upwards in the lateral lobes of a 
child who has died of tubercular meningitis, without any definite signs of 
their presence having been given during life. In cases of cerebellar tumour 
which have proved fatal, a cheesy mass may be found which has, perhaps, 
become adherent to the posterior fossa of the skull and tentorium, and has, 
very likely, extended across the middle line, encroaching on the medulla, 
and so compressed the motor tracts passing downward to the cord. Another 
pressure effect is the compression of the straight sinus by the stretching of 
the tentorium and a consequent pounding up of the blood in the venae Galeni, 
and chronic effusion of fluid in the lateral ventricles. A large cerebellar 
tumour is almost certain to be accompanied by chronic hydrocephalus, the 
lateral ventricles are greatly dilated, the skull thinned, and perhaps the pons 
may be more or less compressed and flattened by the pressure of the fluid. 
A tumour of the middle lobe is more likely to compress the motor tracts in 
the floor of the fourth ventricle than one in the lateral lobes. A simple cyst 
in the cerebellum is not uncommon. 

Symptoms. — The history obtained from the friends usually includes 
headache, more or less vomiting, and squint. In young children it may 
be that enlargement of the head and more or less blindness are early 
noticed. 

An examination of the patient elicits the fact that the headache is either 
frontal or occipital, and of varying intensity ; in one of our cases the pain 
was always referred to the right occipital region, and the boy would sometimes 
be found asleep with his hand placed on this spot. At the post-mortem 
examination a large sarcomatous tumour was found in the right lobe of the 
cerebellum. It is, however, not common for the patient to be able to 
localise the lesion in this way. The headache is usually described as an 
' ache ' rather than as a sharp pain, but in some cases we have known it to 
be intense, suggesting the presence of meningitis. The vomiting, like 
cerebral vomiting generally, is fitful and uncertain ; as a rule it is not per- 
sistent, and it comes and goes in an erratic manner. It is rarely troublesome 
when the patient is at rest in bed. Internal squint is in our experience an 
early and frequent symptom ; it is not always double, and sometimes one 
eye is affected more than the other ; the strabismus is due to a paresis of the 
sixth nerves, and not to a spastic condition of the internal recti. In one case 
coming under our notice a boy who suffered from headache, and who had 
developed an internal squint, was operated on for the strabismus by a 
surgeon ; the latter, however, altered his opinion with regard to the case 



494 Diseases of the Nervous System 

when lie discovered optic neuritis to be present. The boy had a cerebellar 
tumour. Optic neuritis is a common and early symptom ; greater or less 
limitation of the field of vision and blindness usually follow. 

In all cases there is sooner or later a peculiar gait or walk, due to more 
or less weakness in the legs. This peculiar gait is often described as 
'ataxic,' and 'cerebellar ataxia' is sometimes said to be present ; or there is 
a staggering gait, or a difficulty in maintaining the equilibrium. Sometimes 
attention is called to a patient's supposed tendency to fall forward or back- 
ward, or to one side. Now it is certainly true that the patient's friends often 
give a history of staggering or easily falling, and if a child with a cerebellar 
tumour is got out of bed and made to promenade up and down the ward, he 
will most likely sway and easily fall, or he may start forward, as if wound up, 
in a clumsy headlong way. But we confess we are sceptical with regard to 
the existence of a. special ' cerebellar ataxia,' and we cannot call to mind any 
case in which we could satisfy ourselves that it existed. The gait of a child 
with a cerebellar tumour is very much that of a child learning to walk ; there 
is a good deal of clumsiness and a great readiness to fall, but this is due to 
a weakness or paresis of the limbs, and not to ataxia. When there is a spastic 
rigidity, with an over-action of the gastrocnemius group and of the flexors of 
the knee, there is necessarily a clumsy gait with a tendency to fall forward. 
We have never been able to satisfy ourselves that in any given case, apart 
from the results of a spastic rigidity, there was a tendency to fall on one 
side or in any given direction. An increased tendon-reflex is indeed the 
rule, but occasionally it is certainly absent or diminished. We cannot give 
a reason for this, and we doubt the correctness of the one that has been 
given — namely, that it is due to a destructive lesion of the cerebellum. 

Enlargement of the head is common ; this takes place early in young 
children on account of the readiness with which the cranial bones yield to 
the internal pressure, but it may take place also in children of six or seven 
years of age. 

Eclampsia is not uncommon ; the general type is that which consists 
entirely of tonic spasms ; there is retraction of the head, rigidity of the limbs, 
and frequently opisthotonos. Death may take place in one of these attacks 
on account of the spasms of the respiratory muscles. 

Facial paralysis, mostly single and slight, and also nystagmus, are among 
the occasional symptoms. 

In the later stages, should the patient survive, the limbs pass into a 
condition of semi-rigidity ; at first this is temporary, but later it becomes 
permanent. The arms as well as the legs are affected, while the head 
becomes more retracted and fixed. Marked wasting is certain to ensue in 
the late stages, and various trophic changes, such as sloughing of the eyes 
and bedsores, generally follow. 

Are the above symptoms the result of a destruction of a portion of the 
cerebellum ? In our view the answer must be in the negative ; they are the 
symptoms produced by a gradually increasing dropsy of the ventricles, due 
to the tumour of the cerebellum stretching the tentorium cerebelli, and 
obstructing the return of blood from the veins which drain the ventricles, 
and which empty themselves into the straight sinus. If the cerebellar 
tumour produces any symptoms per se, they are masked by those produced 



Tumours of the Cerebellum 495 

by the hydrocephalus. In connection with this we may bear in mind that 
cases have been reported in which there has been k congenital absence of 
one half of the cerebellum, and in which no symptoms have been observed 
during life. As a result of this obstruction of the venae Galeni, fluid is pent 
up in the lateral ventricles and also in the third and fourth, and the sur- 
rounding parts are compressed. All the ventricles become dilated, the 
aqueduct of Sylvius becomes large enough to admit the forefinger, and the 
pons is flattened. The sixth nerves are compressed beneath the pons, giving 
rise to internal strabismus, and the facial may be compressed also. Pressure 
of the fluid on the motor tracts gives rise to the paresis of the limbs and 
consequently to staggering gait, and at a later stage to spastic rigidity. The 
headache is presumably caused by the stretching of the tentorium. Whether 
the choked disc is the result of a reflex irritation, or of a disturbance of the 
circulation, is an open question. It is curious to note that in chronic hydro- 
cephalus, where the large quantity of fluid is due to an excessive secretion 
without any obstruction of the veins, there is only exceptionally paralysis of 
the sixth nerves and rarely optic neuritis, though there may be blindness. 
These cases, however, are either congenital or commence in early infancy 
before the sutures have united, so that tension is relieved by the enlargement 
of the skull. 

With regard to the differential diagnosis between hydrocephalus, the 
result of the growth of a cerebellar tumour, and hydrocephalus due to sub- 
acute meningitis, or to a chronic simple effusion, difficulties are certain to 
occur. In infants or young children suffering from enlargement of the head, 
vomiting, and rigidity of the muscles of the neck with retraction of the head, 
we may be in doubt whether the child suffers from a chronic basal meningitis 
or from a cerebellar tumour. In these cases the temperature might help, 
there being in all probability an evening rise of a few degrees in meningitis, 
while the presence of optic neuritis would favour the diagnosis of tumour. 
In simple effusion the case is usually very chronic, and optic neuritis rarely 
occurs. 

Our experience of tumours of the middle lobe of the cerebellum is very 
limited. We should be inclined to expect that the most prominent symptoms 
would be those caused by direct pressure on the floor of the fourth ventricle. 
This certainly was the case in a patient of our colleague, Dr. H. R. Hutton, 
the most marked symptoms being retraction of the head and neck, coming 
on in paroxysms and accompanied by severe pain, apparently due to the 
cramp of the muscles. At the post-mortem examination a cystic tumour of 
the inferior vermiform process was found, which had pressed upon and 
flattened the floor of the fourth ventricle. 

To sum up as regards diagnosis. The symptoms of a tumour of one of 
the lateral lobes of the cerebellum are those of a gradually increasing hydro- 
cephalus, with the addition of optic neuritis and vomiting. It is only occa- 
sionally possible to say on which side the tumour is situated, and then only 
by means of the pain, which may be referred to the actual spot. The so- 
called ataxic gait is due to paresis or semi-rigidity of the limbs. When the 
tumour occupies the middle lobe the most marked symptoms are retrac- 
tion of the head and neck, arching of the back and exaggerated tendon- 
reflex. 



496 Diseases of the Nervous System 

Tumours of the Pons and Medulla. — Tubercular masses not infre- 
quently invade the pons, being situated in the central part, or small masses 
may be found in the floor of the fourth ventricle. They are apt to cause 
symptoms, less, perhaps, by their direct pressure effects, as they grow but 
slowly, than from the softening which often surrounds them ; at the post- 
mortem, when the size of the cheesy mass is discovered, we have often been 
surprised how little paralysis was present during life. Gliomas of the pons 
are not rare in older children. 

Symptoms. — The combination of symptoms in disease of the pons varies 
much in different cases ; this is due to the close proximity of the motor 
tracts and the centres of various cranial nerves. The paralyses produced by 
disease of the pons are apt to be bilateral, on account of the right and left 
motor paths and nerve centres being near together. The symptoms vary 
according to the position of the lesion in the pons ; thus in a case of our 
own, in which a glioma commenced in the right lower border, there 
was ' crossed paralysis,' viz, a left hemiparesis with paralysis of the right 
external rectus, and right facial paralysis, optic neuritis, and vomiting. 
Cheesy masses are often more centrally situated, and may after a while 
involve the medulla ; there may then be double facial paralysis, perhaps 
more marked on one side than the other ; the saliva dribbles from the mouth, 
the speech is thick, and there may be difficulty in swallowing. There 
may be paresis and rigidity of the limbs, squint, and sloughing of the cornea 
from interference with the fifth nerve. 

Basal Ganglia and Internal Capsule. — Cheesy masses maybe present 
in the caudate or lenticular nucleus or thalamus, but they only produce a 
definite hemiplegia when they involve the internal capsule. In one of our 
own cases a villous growth from the choroid plexus compressed the left 
thalamus and internal capsule, and produced a paresis of the right arm and 
leg, with marked rhythmical shaking movements when voluntary action was 
attempted, so much so that his mother said his arm used to ' work like a 
clock ; ' contractures, facial paralysis, and optic neuritis supervened before 
death. The rhythmical tremors were no doubt produced by gradual pres- 
sure on the motor path which passes along the internal capsule. In children 
there is rarely loss of sensation : this occurred, however, in one of our cases, 
in which two large cheesy masses involved the whole of the posterior limb of 
the internal capsule, the arm and leg of the opposite side being contracted 
and anaesthetic. 

Tumours of the Cortical Layer. — Irritation of any part of the motor 
area of the cortex, which includes the ascending frontal and parietal con- 
volutions and the anterior portion of the superior parietal lobule, gives rise 
to convulsions, which begin in the arm, leg, or face, according to the part 
affected. Destruction of this region, as by softening following embolism, 
or the presence of a tumour, gives rise to a hemiplegia affecting the face, 
arm, and leg, a partial destruction giving rise to a partial paralysis. The 
presence of a syphiloma, a tubercular mass, or pressure by a tumour growing 
from the membranes, is likely to give rise to epileptiform seizures, the con- 
vulsions starting in the arm, leg, or face, though they are not necessarily 
confined to the limb in which they start, but may become general. In the 
later stages a hemiplegia results. 



Tumours of the Frontal Lobe 497 

Tumours of the Prontal lobe produce no paralysis unless they encroach 
upon the ascending frontal convolution : in that case they may produce a 
paresis of the leg, arm, and face, according to the part involved. A tumour 
involving the posterior third of the left frontal convolution causes aphasia. 

Prognosis. — The prognosis in cerebral tumours is exceedingly unfavour- 
able, whatever their nature may be, unless perhaps syphilis may be excepted. 
Undoubtedly tubercular masses may cease to spread and become cretaceous, 
though against this must be set off the chance that other masses may form, 
or the child die of tubercular meningitis or tubercle elsewhere. Every other 
form of tumour is certain to progress from bad to worse. In the majority 
of cases the progress is slow, often lasting over a year or more. Death may 
supervene from intercurrent disease, as tubercular meningitis, or other form 
of tubercle ; it may be sudden in tumours of the pons and cerebellum, or it 
may be exceedingly slow, as in cases of cerebellar tumour and chronic 
hydrocephalus. Occasionally cases in which the diagnosis of tumour is 
made partially recover, or remain stationary for many years. Gowers 
records a case of a girl of fifteen years who suffered from hemiplegia, head- 
ache, hemianopia, and optic neuritis of gradual onset ; she gradually re- 
covered, except the hemianopia and paresis of arm, and was well, with these 
exceptions, six years after. In a case of a girl aged ten years, who was 
seen by the late Dr. Ross and one of ourselves, there could be little doubt 
that there was a cerebellar tumour, as there was optic neuritis and spastic 
condition of both legs ; she eventually recovered while under the care of a 
quack, but became quite blind. 

It is not uncommon to find cretaceous masses in the brain, evidently the 
result of the shrivelling up of a tubercular mass. This was so in the follow- 
ing case : 

Cheesy Tumour of Cerebellum; Temporary Recovery. — A boy aged u- years was 
admitted into hospital, November 1881, with internal squint, optic neuritis, and almost 
complete blindness. He was intelligent and walked about ; there were no signs of any 
paralysis, he had no headache or vomiting ; during his stay he got better, and was dis- 
charged (January 1882) apparently in good health, though quite blind from optic atrophy. 
He was re-admitted February 1883, having suffered for six months with pain in his head, 
and recently he had lost power in the right side ; the right elbow was semi-flexed, the 
wrist pronated and flexed, the fingers over-extended, except at the metacarpal joints ; the 
knee was bent, and the ankle in the position of equino- varus ; there was also loss of sen- 
sation on the right side, and the boy had some difficult}- in finding the right arm with his 
left. In March there was some difficulty in swallowing, with paresis of left side of face 
and arm, followed by death. At the post-mortem there was a small cyst, with thickened 
cretaceous wall on the inferior surface of the right frontal lobe, evidently the remains of 
a tubercular mass ; there was a cheesy mass involving the left caudate nucleus and optic 
thalamus and internal capsule ; there was a second cheesy mass involving the lenticular 
nucleus and internal capsule of the right side. In this case there is no doubt there was a 
cheesy mass in the right pre-frontal lobe on the inferior surface, which gave rise to optic 
neuritis and internal squint, and which passed into a quiescent state ; subsequently other 
tubercular masses formed, which, with a general tuberculosis, caused his death. 

Diagnosis. — The most important point to be decided is whether there is 
a cerebral lesion, or the symptoms are due to functional disease ; the question 
as to the nature and seat of the lesion is of less practical importance. The 
cases which at first sight present a superficial resemblance to cases of 
cerebral tumour are those of chronic headaches in children at puberty, which 

K K 



498 Diseases of the Nervous System 

are often severe, and are sometimes accompanied by vomiting or nausea. 
The latter, however, are never accompanied by optic neuritis or by sudden 
vomiting - , are rarely acutely painful, and are improved, or got rid of for a time, 
by active exercise in the open air. The headaches of a cerebral tumour are 
severe, sometimes make the patient scream with pain, and are made worse 
by active exercise. 

The vomiting in a case of cerebral tumour is erratic ; it may come on the 
first thing in the morning, is perhaps constant for a day or two or more, 
then passes away for awhile without any apparent reason. The paralyses 
of hysteria are not often hemiplegic, being more often paraplegic, and are 
never accompanied by optic neuritis. 

When fits are present there may be a difficulty in distinguishing between 
epilepsy and a tumour, especially as a hemiparesis is apt to remain after a 
fit. In these cases, if the convulsions have constantly a local commencement, 
they are probably due to a tumour, and later on optic neuritis or some 
paralysis would decide the diagnosis. The presence of more tumours than 
one may make the differential diagnosis difficult. 

Ti'eatment. — Except in the case of syphilomas of the brain, the treatment 
of cerebral tumours by medicines resolves itself into a treatment of symptoms. 
Wherever there is the least chance of the tumour being syphilitic, iodide of 
potassium should be given in full doses, though in children gummatous disease 
of the brain is rare. If it is supposed that the tumour is tubercular, cod- 
liver oil and iodide of iron may be prescribed, while the child is kept at rest, 
and placed under the most careful hygiene. 

For the headaches, bromides, Indian hemp, and opium may have to be 
prescribed. The vomiting, which is so often troublesome, must be treated 
by perfect rest in bed, peptonised milk or iced drinks being given in small 
quantities. Hydrocyanic acid may be given. The vomiting is exceedingly 
erratic, coming and going without any apparent cause. In some tumours at 
least the question of operation may be entertained (see infra). 

Cerebral Abscess. — In children, as in adults, the common cause of 
abscess of the brain is injury or ear disease ; less often it is the result of 
suppuration in a distant part, as an empyema or abscess of lung. Abscess 
is most common in the cerebrum, less frequent in the cerebellum or pons. 

Symptoms. — The early symptoms are those more or less of meningitis, 
namely headache, fever, vomiting, and perhaps convulsions ; they may, how- 
ever, be very slight and readily overlooked. The later symptoms, those of the 
chronic stage, vary according to the seat of the abscess, and are more or less 
those of a cerebral tumour, including optic neuritis, headache, vomiting, 
convulsions, and varying paralyses, also perhaps hectic, and emaciation. The 
diagnosis of abscess from meningitis or tumour is sometimes very difficult, 
as the following cases show. A girl of two years of age, who was admitted 
into hospital under Dr. Hutton, had had a discharge from her right ear for 
three months, but was otherwise well and strong, till fourteen days before 
admission, when she had a right-sided convulsion lasting four hours, followed 
by unconsciousness ; four days afterwards she had a similar attack : she 
squinted, and was more or less blind after it. On admission there was 
almost complete motor and sensory paralysis of the right arm and leg, with 
loss of sensation on the left side of the face and ptosis on the left ; she became 



Cerebral Abscess 499 

convulsed, the convulsions beginning in the right side, and was unconscious 
before death. At the post-mortem an abscess cavity was found in the left 
temporo-sphenoidal lobe, extending into the occipital lobe and reaching the 
internal capsule : it contained three ounces of pus. The left tympanum was 
full of pus. In the following case the abscess followed a perforating wound 
of the orbit. A boy aged six years was playing in a hayfield when by accident 
he was wounded above the left eye with the prong of a hayfork ; the eye 
swelled, but no external wound was found. During the next few weeks he 
was irritable and frequently vomited. Six months after he was brought for 
advice, as his sight was failing. On admission he was quite blind (atrophy 
of discs) and somewhat dull of comprehension ; he could walk well ; the right 
hand was weak, but not paralysed ; he remained much the same for a month, 
when he died suddenly. At the post-mortem the left frontal lobe was larger 
than that of the opposite side, its convolutions, including the superior, middle, 
and inferior, with more or less of the ascending frontal and parietal, flattened ; 
its inferior surface was adherent to the orbital plate and of a yellow tinge ; 
and there was an abscess containing four or five ounces of greenish pus. It 
was clear there had been a penetrating wound through the orbital plate into 
the brain. 

Treatment. — When pus has formed there is little hope in any method of 
treatment, except operation. 

Surgical Treatment of Cerebral Lesions. — Our knowledge of the operative 
treatment of tumours of the brain is still very limited, but enough has been 
learnt to justify a short account of the subject being given here. At present 
only those growths which lie on or near the surface of the cerebrum have 
been successfully dealt with ; tumours at the base of the brain, or involving 
the basal ganglia, may be looked upon as inaccessible to surgery at present, 
and, though cerebellar growths are not beyond our reach, but little has yet 
been done for their removal. Surgery chiefly deals with growths situated in 
the motor area of the cortex, since the localisation of the tumour is most 
satisfactorily to be made out in this region. Again, only those growths 
which are of limited size are suitable for removal, since the destruction or 
disturbance of large areas of the brain would lead to as great evils as the 
tumour itself. Assuming that the presence and exact position of a tumour 
have been ascertained by the symptoms presented, the following are the 
steps to be taken for its removal. If time permits, at least twenty-four hours 
should be devoted to preparation of the patient for the operation. The 
entire scalp should be shaved and thoroughly cleansed with turpentine ; after 
this a compress soaked in solution of corrosive sublimate, 1 in 3,000, or 
carbolic acid, 1 in 40, should be kept applied to the head for an hour before 
operation. The utmost precautions should be taken to have all instruments, 
and anything likely to come into contact with the field of operation, thoroughly 
aseptic. After the child has been anaesthetised, a large flap of integument, 
having its centre over the seat of the tumour, should be reflected and the 
bone laid bare. Next a large circle of bone should be removed with a trephine 
or gouge, or saw, and the dura mater exposed : the opening must then be 
enlarged by cutting forceps or saw as maybe required. All bleeding must be 
arrested. The surface of the dura mater should then be carefully examined 
as to its colour, as to the presence of pulsation, and as to any tendency to 

k k 2 



500 Diseases of the Nervous System 

protrusion through the aperture in the skull. We have noticed in a case of 
cerebral tumour thinning of the bone over the seat of the growth, with en- 
gorgement of the diploic vessels, but this can only be expected to be seen 
when the growth is large and superficial. Should the tumour be extra-dural, 
its removal may be now accomplished ; but if it is truly cerebral, a crucial 
incision should be made in the membrane, and the surface of the brain 
inspected and felt with the finger for evidence, either visible or palpable, of 
the mass ; if the growth is seen, its size and connections should be studied, 
and the question of the possibility of its removal decided upon. If it is 
determined to proceed with the operation, the substance of the cortex must 
be separated from the growth, and the mass removed with as little injury 
as possible, both to brain substance and to the vessels of the part. If there is 
softening" (encephalitis) of the brain round the growth, the prognosis is bad, 
but any actually disintegrated brain should be removed. All bleeding is then 
to be arrested, the dura mater sutured over the brain, and the portion of skull 
removed, which should have been kept lying in warm carbolic lotion (i in 80), 
may be cut up into pieces about the size of canary seed, and replaced on the 
surface of the membrane ; or the whole disc of bone may be replaced entire ; 
even, however, if the bone is not replaced, the gap is largely filled up by 
bone. In some cases, of course, it is desirable to have the aperture yielding, 
so that it may give way before increased intra-cranial pressure. Provision 
may be made for drainage, or the wound may be closed and dressed anti- 
septically in the ordinary fashion. After the operation the child is kept 
absolutely quiet in bed, and fed on weak animal broths and diluted milk in 
small quantities. If the case is doing well, there will be no need to disturb 
the dressings for a week or ten days, when the Avound will be found healed, 
with the exception of the drain opening. Should no growth be found, or 
should there be very extensive encephalitis, or if the tumour be too extensive 
for removal, the operation must be abandoned. Such are briefly the general 
rules to be adopted in dealing with brain tumours, and a large part of the 
description will also apply to operations for cerebral abscess, or for those 
cortical lesions which give rise to epilepsy or other troubles and necessitate 
surgical measures. A few additional remarks may be made on the two last- 
mentioned subjects. As to cerebral abscess, it is the result, apart from 
tuberculosis, most commonly of injury or disease of the ear : in the case of 
traumatic abscess the seat of the abscess will usually, though not always, 
correspond with the seat of the external injury, though this guide should be, 
of course, supplemented by the indications given by any paralyses that may 
be present. The steps of the operation are those already described ; should, 
however, no evidence of the abscess be seen on exposing the brain, careful 
systematic exploration to a depth of from one to two inches should be made 
in every direction from the centre of the part exposed. This is best done 
with a grooved needle, fine trochar and cannula, or director. Should pus be 
found, the opening must be enlarged and the abscess cavity drained, and the 
operation completed as above described. (For further details of cerebral 
abscess, the result of otitis, vide chapter on Diseases of the Ear.) 

Where trephining is done for Jacksonian epilepsy, it must be remembered 
that pressure or irritation may be due to a depressed or thickened portion of 
bone, to a local pachymeningitis, or to a cicatrix, or to local inflammation of 



Cerebral Haemorrhage 501 

the cortex of the brain itself. If the irritant is cranial, the offending bone 
must be removed. So also, if a local thickening" of the dura mater is found, 
it should be excised. If, however, the lesion is in the brain itself, the ques- 
tion arises whether it is so extensive that removal of the injured part can be 
effected without an extent of paralysis following which would render the 
patient's condition worse than it already is. The details of the operation are 
the same as in the case of tumour or abscess. For further information we 
must refer to the papers of Dr. Macewen, Mr. Horsley, and others. There 
is no doubt that, on the one hand, the brains of children are more tolerant of 
operation than those of adults, and, on the other hand, that brain lesions 
which would prove fatal to adults are not only recovered from in children, 
but may leave little or no permanent effects, even if left to nature. Each 
case must be judged on its merits. 

The dangers of hernia cerebri and diffuse encephalitis or meningitis are 
no doubt considerable, but with thorough antisepticism these risks may be 
generally avoided. It has been shown by Dr. Macewen that hernia cerebri, 
though it may result from imperfect wound management, may also be due to 
a pre-existing encephalitis, even in the absence of any septic condition of the 
wound. Should hernia cerebri appear, it is best dealt with by pressure 
applied over the wound by means of a plate of sheet-lead laid outside the 
inner layer of dressings. 

The subject of operative measures in disease and injury to the spinal 
cord is still more in its infancy than is that of cerebral surgery, and no definite 
rules can be laid down ; some account of the matter will be found under the 
head of Spinal Caries and Spina bifida. 

It must be looked upon at present as a much more serious matter to open 
the spinal theca than to incise the dura mater ; hence greater hesitation 
should be felt in dealing with cases requiring so severe a measure. 

Cerebral Haemorrhage 

We have already remarked (p. 19) that cerebral haemorrhage occurring 
in early life is hardly ever the result of a ruptured artery. Haemorrhage 
does, however, not infrequently take place from the venous capillaries on the 
surface of the brain, and also, though in less degree, into the grey and white 
matter. The pia mater and its capillaries are exceedingly delicate in the 
infant, and when distended with hypervenous blood, as during some inter- 
ference with the respiration, they are exceedingly liable to rupture or to allow 
the blood to ooze through their walls. Hypervenous blood appears more 
readily to escape from the vessels by oozing than does ordinary blood. 
Meningeal bleedings of a larger or smaller amount are constantly found in 
infants who have been born asphyxiated, or who only survive their births a few 
days in consequence of feeble respiratory powers (see fig. 5). The same con- 
dition is seen in infants -who have been ' overlain in bed,' and in those who 
have died in convulsions. Clots of various sizes may also be found in the 
central white matter, in the internal capsule, and in the masses of grey matter 
at the base of the brain. The younger the infant the greater will be the 
brain damage done by the bleeding, as the brain is exceedingly soft at birth 
and easily injured ; the more immature the brain, the more is its develop- 



5o: 



Diseases of the Nervous System 



ment likely to be interfered with. As the result of the brain dan 
there may be hemiplegia, diplegia, paraplegia, or idiocy, with or without 
paralysis. The paralyses which date from cerebral haemorrhage at birth 
are mostly more severe than those which follow haemorrhages in older 
children. Cerebral haemorrhage apart from a meningeal bleeding, when it 
occurs during early life, takes place in ' bleeders,' and often as the result 
of a blow. 





Fig. 103. — Spastic Faralysis, the result of 
Meningeal Haemorrhage at Birth. Willie 
G., aged 8 years. The weight of the body 
is partly supported by being held up by the 
arms, partly by resting on the toes. 




Fig. 104. — Willie G., after division of the 
tendo Achillis and forced dorso-flexion. 



Post-partum Meningeal Haemorrhage. Birth Palsy. — A delayed 
labour from any cause is liable to give rise to asphyxia, the vessels of the pia 
mater being gorged with dark venous blood, and a leakage takes place, the 
blood oozing from the distended vessels. The damage done by the pressure 
of the clot forming on the convex surface of the brain may be sufficient to 
permanently injure the cortical motor or other cortical centres. The newly 
born infant's brain is exceedingly soft and readily injured, as anyone knows 
who has attempted to remove one post mortem without damage; if the 
slightest injury is done to the brain by the saw in dividing the skull, the 



Post-partum Meningeal Hemorrhage 503 

brain substance will ooze out of the saw-cut almost like clotted cream. Now, 
not only may considerable damage be done to the brain by a comparatively 
small surface haemorrhage, but as the cortical centres are imperfectly developed 
at birth, the pressure of a clot or a rupture of the grey matter may readily 
prevent growth and development. The consequences of this brain damage 
are various, but are often not very apparent for some months or more 
after birth. The mental powers may never properly develop, though 
the limbs are strong, and the child is mentally weak or an idiot ; or the 
lower extremities are stiff and weak, or there is a paresis of hemiplegic 
distribution, the child generally also being mentally deficient. In all a history 
of a prolonged labour, or of being 'born blue,' can be obtained. 

A whole family is often more or less affected when the mother has a 
narrow pelvis, or for various reasons has difficult labours ; some of the 
infants may escape if born before they are fully developed. First-borns are 
apt to suffer the most, as can be readily understood. 

The following history of a family may form an illustration of the damage 
which may be done by difficult labours. Mrs. G. has always difficult labours 
in consequence of a narrow pelvis. She has had seven children born at or 
near full time. 

1. Willie, eight years old, suffers from spastic paraplegia and is mentally 
deficient (figs. 103 and 104). (An inmate of the Royal Albert Asylum.) 

2. John died at thirteen months, of convulsions ; ' head never was right. 5 

3. Clara, six years, is all right. 

4. Baby, died soon after birth. 

5. Baby, born dead. 

6. Boy, two years old, is all right. 

7. Girl, four months old, both legs semi-rigid, exaggerated tendon 
reflexes, ankles rather stiff. 

In this family of seven, two appear to have escaped uninjured ; of the 
remaining five, two are living, having sustained a brain damage, and three 
are dead, their death no doubt being directly due .to a birth-injury to the 
brain. 

Symptoms. — -The most common symptom which immediately follows 
the meningeal haemorrhage is convulsions ; sometimes there is paralysis, 
and there may be rigidity. In the great majority of the cases there is no 
marked paralysis immediately following birth, or at any rate it escapes the 
mothers attention, and it is only at the end of the first year that it is noticed 
there is stiffness about the child's legs, which prevents it from walking or 
from making any attempts to walk. Mostly, however, when the infant is a 
few months old, a careful examination of the lower extremities will reveal an 
exaggerated knee-reflex and a stiffness of the ankle joints. In some cases 
there is over-action of the adductors of the thighs, so that the legs are con- 
stantly crossed, with probably also more or less talipes equino-varus. Both 
arms may be affected, or an arm and leg only ; there is usually backwardness 
in talking. When the symptoms are fully developed, as they usually are at 
two or three years of age, the rigidity of the limbs, most frequently the legs, 
is very characteristic ; there is ' spastic paraplegia.' In a severe case the 
child cannot walk or stand unaided, and lies helplessly in bed ; the knees are 
semi-flexed, with adductor spasm, the tendo Achillis is drawn up, so that the 



504 



Diseases of the Nervous System 



foot is in a position of equino-varus, there is exaggerated knee-reflex, and 
ankle clonus. In some instances the child, though unable to stand or walk 
without help, on account of the talipes cquinus present, can crawl, and may 
learn to do this fairly well ; this was the case with Willie G. (see fig. 103). 
This condition may remain throughout life, and occasionally adults belong- 
ing to this class may be seen crawling on all fours in the streets, and gaining 
their livelihood by begging. 

Many, perhaps the majority of cases, learn to walk in some sort of a 
fashion, but with difficulty, on account of the spasm of the gastrocnemii and 

the consequent tendency there is to fall 
forwards, and the awkwardness and 
want of control over their movements. 
The arms are more rarely affected 
than the legs ; sometimes there is 
slight rigidity in one only or in both, 
which interferes with their use, or the 
elbow is flexed, the wrist flexed and 
pronated, and the fingers flexed at the 
metacarpophalangeal joints. There 
may be present the irregular move- 
ments known as athetosis (see p. 508). 
Sometimes there is slight facial para- 
lysis, only noticeable when the child 
laughs or cries ; we have never seen 
it well marked. 

The 'child is usually backward in 
talking, and in some cases where the 
mental defect is marked they never 
can utter anything but meaningless 
sounds. The mental condition varies ; 
sometimes there is complete idiocy, 
more often some loss of intelligence, 
or the child is emotional, being easily 
roused to anger, and, if going to school, 
is teased and tormented by. its com- 
panions. The shape of the head is 
often unaltered ; occasionally, it is 
small and more or less flattened in 
the parietal regions (see fig. 105). 
Cerebral Haemorrhage occurring after Birth. Acute Cerebral 
Palsy. — Cerebral haemorrhage may occur from various causes besides those 
in operation during the act of birth. Blood may ooze on to the surface of 
the brain or into the white or grey matter during over-distention of the 
cerebral veins from any cause. The commonest cause is a series of con- 
vulsions. Haemorrhage may occur, however, during whooping cough, or in 
severe vomiting, or in any cases in which there is a severe venous congestion 
of the brain. We have several times seen post mortem a meningeal bleeding 
"in infants who have died in convulsions, and also after whooping cough. 
Such haemorrhages are most common during the first two years of life — 




Fig. 105. 



-Birth Paralysis, Spastic Paraplegia 
Mental Feebleness. 



Cerebral Hemorrhage 505 

indeed, they are uncommon at any other period, and this is to be expected 
when we remember how much more delicate the capillaries and cerebral veins 
are during infancy than in later life. 

The convulsions which immediately precede the haemorrhage may be 
the result of many different conditions. Sometimes the primary illness is 
measles, acute diarrhoea, pneumonia, whooping cough, or scarlet fever ; more 
often, perhaps, the attack cannot be referred to any one of these, and the 
principal symptoms are high fever and drowsiness, and then the convulsions 
supervene ; then, after a series of convulsions, a more or less well-marked 
hemiplegia is noted. Such cases are often looked upon as ' brain fever ' or 
' congestion of the brain.' In some cases there is a history of a fall. In other 
cases the convulsions are undoubtedly reflex, especially from colic. A high 
temperature, 105 to 106 , seems to excite convulsions. 

In all cases we have noted the convulsions were severe, often one-sided 
at first, but tending to become general ; they may last from a few hours to a 
week ; the infant may remain a long time in a state of coma. Probably a 
small amount of bleeding may take place without producing any symptoms, 
and absorption takes place and no ill effect remains. In others there may 
be a slight and transient paresis of an arm or leg or both, such as is sometimes 
seen after an epileptic fit. In another class no paralysis is left, but the child 
grows up with feeble mental powers which date from the time of the con- 
vulsions. In a common class of case a more or less complete hemiplegia or 
diplegia is left, with perhaps more or less facial paralysis. 

As an instance of reflex convulsions giving rise to cerebral haemorrhage 
we may relate the following case : 

Convulsions ; Cerebral hcemorrhage. — George L. , aged 12 years, was brought to the 
Children's Hospital, Manchester, suffering from tuberculosis and also hemiplegia ; his 
mother gave the following history. He was strong and healthy when born, though the 
labour was somewhat tedious. There was no history of hereditary syphilis. He walked 
at twelve months of age, and was well and strong till two years of age. At this time he 
had a fit, which was attributed to his eating some crust of apple pie some half an hour 
before the attack. He was playing on the doorstep at the time ; he suddenly became 
' black about the mouth,' and would have fallen but for another boy who caught him in 
his arms. The fit, including the unconscious state which followed, lasted about ten 
minutes. Two weeks after he had another fit, which lasted half an hour, and was more 
severe than the first ; his right arm and leg were especially convulsed. After this fit it was 
found that his right arm hung useless, and in trying to walk he dragged the right leg. 
The face was unaffected. The arm was always worse than the leg ; at first he could not 
hold anything in it. Both arm and leg slowly improved, but have remained more or less 
stiff and rigid. Ever since the first convulsion he has been subject to fits, but he has not 
had any for the last two years. He has had on an average two fits a week, from 
two years of age till he was ten years. They only lasted some minutes, accompanied by 
loss of consciousness ; he always knew when a fit was coming on by his right thumb begin- 
ning to ' work.' He used to say, ' Mother, my thumb's working ; ' then he would fall over 
almost immediately if not caught. The fits were mostly right-sided, but the left arm and 
leg would also ' work. ' Lately he has used his right arm more than formerly, being able 
to hold things in it. 

When examined (September 8, 1890) it was evident he was affected with an old 
hemiplegia : he could walk, but dragged his right leg after him. He could use his right 
arm for holding things, but could not feed himself with it ; the shoulder joint was fairly 
movable, the elbow bent and semi-rigid, and the hand pronated ; the stiffness could be 
overcome by slight force. The right leg was somewhat stiff at the knee and slightly 



506 



Diseases of the Nervous System 



flexed as he lay in bed, with the foot pointed. There was exaggerated knee reflex on the 

right side. There was DO evidence of any mental weakn 

He died of tuberculosis in February 1891. The post-mortem was made by Mr. R. O. 
Bowman, senior resident medical officer at the Children's Hospital; we examined the 
brain next day. An examination of the outer surface of the brain showed it to be per- 
fectly normal, the membranes were healthy, there was no flattening of the convolutions or 
any evidence of an old surface haemorrhage. The internal parts were examined by making 
transverse sections. The first section taken through the centrum ovale showed nothing 
abnormal. A section made exposing the lateral ventricles, without slicing the corpus 
striatum, showed an old cyst (fig. 106, A) with brownish contents, £ inch in length, 
situated on the left side in the white substance between the fissure of Rolando and the 
corpus striatum ; and four small cysts i; B situated on the right side in the white substance. 




Fig. 106. — Horizontal Section of Brain, exposing lateral ventricles (xj), f r, fissure of 
Rolando ; a, old blood cyst ; b, b, b, b, small blood cysts. Haemorrhage at two years 
of age ; death at twelve years of age. 



The cyst marked A was apparently about h inch in depth. There was no sclerosis or 
induration in the neighbourhood of the cysts. A third section made 'ower than the above, 
and on a level with the upper surface of the cerebellum, and slicing the optic thalamus, 
caudate nucleus, and internal capsule (fig. 107), showed the lower limit of the cyst seen in 
fig. 106, a second old blood-cyst B, and another small one at c. Another similar cyst was 
found in the white substance of the frontal region at a lower level than fig. 107. 

Sections of the cord made in the cervical, dorsal, and lumbar regions did not show- 
any sclerosis or wasting of the descending tracts ; neither was there any wasting of the 
internal capsule or crura. 

In reviewing the history of the case, in the light of the morbid anatomy, 
there is much reason to believe that a multiple haemorrhage took place when 



Cerebral Hcemorrhagt 



507 



the boy was two years of age, and that one or more (a, fig. 106) of the 
haemorrhages gave rise to the paralysis by the destruction of some of the 
white fibres en route from the motor-surface centres to the internal capsule. 
There seems to be little room for doubt that the initial convulsions were the 
cause and not the consequence of the multiple haemorrhages. It is hardly 
conceivable that the multiple haemorrhages should be caused by any throm- 
bosis, embolism, or arteritis ; they must presumably have been due to a 
sudden engorgement of the veins due to asphyxia, such as takes place in a 
fit in consequence of spasm of the respiratory muscles. 

As an example of a hemiplegia following convulsions associated with 
measles the following case occurring in a healthy boy of twenty months, a 




Fig. 107. — Horizontal Section through Brain at a lower level than fig. ic6, showing 
Thalamus and Caudate Nucleus ( x |). a, b, c, old blood cysts. 



Optic 



patient of Mr. Wilson of Cheadle, which came under our observation, may 
be taken as an example. Mr. Wilson's notes are as follow : 



Measles ; Pneumonia ; Convulsions ; Hemiplegia. — Boy, twenty months. The measles 
rash was first noticed on May 10 ; convulsions commenced at noon on the nth : these 
consisted of clonic spasms of the right arm and leg and right side of the face ; the eyes 
were turned to the right side and fixed ; the pupils were dilated, the temperature rose to 
105 , the pulse was too fast to be counted ; the convulsions continued during the morning ; 
at 1 P.M. the temperature was 107° F. , when the patient was put into a cold bath ; it was 
again 107 at 4 P.M., when he was bathed again and five grains of quinine given by the 
rectum ; at this time an examination of the lungs showed pneumonia at one base ; at 6 P.M. 
the temperature was io3 r , and the mother noticed he had lost the use of his left side ; at 



508 Diseases of the Nervous System 

8 P.M. it was noticed that the left arm was completely flaccid, paralysed, and apparently 
anaesthetic ; the leg was rigid, but on tickling the sole of the foot the toes moved slightly. 
Pneumonia developed the next day ; the child died on the 13th, the arm and leg remaining 
in the same condition ; unfortunately, no autopsy could be obtained. The paralysis was 
probably clue to a surface bleeding following the convulsions. 

The following case may be given as illustrative of one which recovered 
from the immediate effects of the acute attack : 

Convulsions ; Hemiplegia. — A child of thirteen months, who was cutting her lateral 
incisor teeth, was suddenly seized with vomiting, diarrhoea, and high fever ; then a series of 
convulsions came on which lasted eight hours, the right side working most ; at the end of 
this time it was noticed she had completely lost the use of the right arm and leg, and the 
face was drawn. Her speech was affected, so that she could not say any of the words 
she had learnt. For more than a month she lay quite helpless. Seven months afterwards, 
when twenty months old, she could not walk or rest her weight on the right leg ; the arm 
was bent at the elbow, the hand clenched, but the facial paralysis had disappeared; she 
could say a few words, but was backward in intelligence. At the age of four years she 
had much improved : she could walk quite well, having apparently regained power in her 
leg, though there was slight equino- varus, but the right arm remained stiff and weak, the 
elbow flexed, the wrist bent and pronated, and the fingers clenched. The fingers closed 
spasmodically, so that she was in the habit of placing things with her left hand between 
the fingers of her right, where they were held without effort. She could talk and was very 
intelligent. 

These cases may be taken as types of acute cerebral paralysis due to 
cerebral haemorrhage ; the symptoms in such may be varied, but they all 
three agree in that convulsions were present and the paralysis set in sud- 
denly and unexpectedly, as a surprise to the attendants. In the second and 
third there was high fever. 

For the succeeding few weeks, if the patient survives, he remains helpless, 
though the condition gradually improves ; if there is anaesthesia, this passes 
away ; the aphasia, if present, disappears ; the face improves, and still later 
more or less power returns in the muscles of the legs. The arm remains in 
part permanently paralysed, and in the course of some months contractures 
come on ; the greatest improvement takes place in the muscles about the 
shoulder ; the elbow is flexed, the wrist flexed and in a position of pronation, 
the fingers are bent up, inclosing the thumb. The amount of paresis and 
contracture varies considerably, according to the severity of the case. 
Peculiar movements often occur in the paralysed limbs, more especially in 
the hands, a condition to which the term ' athetosis ' has been applied. The 
movements as a rule are quite unlike chorea ; they are slow, consisting in alter- 
nate contraction of opposing muscles, giving rise to irregular movements of 
the fingers and hand ; they are involuntary, and take place in muscles in 
which there is ordinarily a certain amount of tonic spasm. The term' mobile 
spasm ' has been applied to this condition by Gowers. As the latter author 
points out, the interossei and lumbricales muscles (which flex the metacarpo- 
phalangeal and extend the phalangeal joints) are mostly affected ; less often 
the long extensor, and never the long flexor of the fingers. 

In consequence, the hand is apt to assume the interosseal position. The 
movements may take place independently in the interossei, so that one or 
more fingers may be extended at a time, or all the fingers may be extended 



Cerebral Hemorrhage 



509 



and separated, and the slow irregular movements of the extended fingers 
suggest the movements of the tentacles of a cuttle-fish (Gowers). The 
movements are involuntary, but are made worse by attempts at voluntary 
movements. 

The paralysed arm is apt to grow more slowly than its fellow, so that it is 
shorter and smaller, and often blue and cold. The leg, following the usual 
course in hemiplegias, recovers more quickly and perfectly than the arm ; 
there is more or less equino- varus, and there may be some shortening, 
but the child can get about fairly 
well. . ^ -~^. 

The intelligence often remains 
impaired ; sometimes there is 
complete idiocy, more often only 
impaired mental powers or back- 
wardness. Epilepsy is also 
common. 

Morbid Anatomy. — If an op- 
portunity occur of examining the 
brain shortly after the occurrence 
of the haemorrhage, blood varying 
in amount from a punctiform 
haemorrhage to a large clot or 
clots will be found beneath the 
pia, situated most commonly at 
the vertex, but also at times at 
the base ; it is usually double, 
but mostly more extensive on 
one side than the other. Blood 
clots may also be found in the 
central white matter, or in or 
about the masses of grey sub- 
stance at the base. There may 
be actual destruction of brain 
substance as a result of the 
bleeding, and probably in most 
cases softening follows. 

If death occurs after some years, atrophic changes of varying amount will 
be found, or there may be old blood cysts, if the bleeding took place into the 
brain tissue. In cases in which there has been a hemiplegia or diplegia, 
the atrophic changes are situated in the motor area. The dura mater may be 
adherent and the pia mater thickened over this area, and instead of fully 
developed convolutions in the ascending frontal and parietal regions a 
scarring or cicatrisation has taken place, no doubt as a result of the softening 
taking place after the haemorrhage. This was the case in the brain of a boy 
recently under the care of our colleague Dr. H. R. Hutton (see fig. 108), and 
also in a case recently shown by Dr. T. R. Railton at the Manchester Patho- 
logical Society. 1 

In Dr. Huttoirs case the skull was thickened and flattened over both 
1 See Medical Chronicle, March 1892, p. 429. 




Fig. 108.— Brain of a boy aged 18 months, showing, 
a, depression over both motor areas, due to menin- 
geal haemorrhage at birth ; B, cerebellum only par- 
tially covered by the occipital lobes. The patient 
had atypical diplegia. (Dr. H. R. Hutton's case.) 



5 io Diseases of the Nervous System 

parietal regions, there was spastic diplegia, the infant was an idiot. At the 
post-mortem the dura mater was found to be adherent to the skull, the pia 
thickened over the motor area and adherent, a well-marked depression or 
sulcus being present over both motor areas. In some cases atrophy of the 
frontal or occipital lobes has been found as a result of the old haemorrhage. 

Treatment. — In connection with the treatment of post-partum cerebral 
haemorrhage, the most important matter is to prevent its occurrence by so 
expediting labour that the infant does not suffer from asphyxia. Much may 
be done to prevent, very little can be done to cure. We are powerless — as 
far, at any rate, as drugs are concerned —to remove a cerebral clot or undo a 
brain damage. Hence the question of immediate trephining to remove the 
blood deserves consideration, and will possibly be in the future a recognised 
mode of treatment in cases where the haemorrhage is local and superficial. 
In those cases in which the bleeding is secondary to convulsions, the most 
important matter is to prevent any further return of the convulsions ; to this 
end the bromides and chloral must be used with a very free hand, and pushed 
so as to render the infant drowsy. Ice should be applied to the head, and 
the head and shoulders kept well raised. A moderate purge should be given, 
sufficiently large to act freely on the bowels ; a piece of mustard leaf may be 
applied to the back of the neck if the child is unconscious, care being taken 
not to leave it on long enough to produce a sore. The drugs most likely to 
be of service are small doses of digitalis, to steady and increase the power of 
the heart, and bromide in full doses if there is any tendency to convulsions. 
The paralysed limbs should be wrapped in cotton wool. As the patient is 
recovering from the effects of the attacks, nux vomica, iron, and syrup of the 
hypophosphites may be given. In the later stages, when contractures are 
setting in, massage should be diligently and intelligently employed ; but the 
patient's friends must be warned that a cure is not likely to be effected by 
any form of treatment, and that rubbing, as also galvanism, is only palliative. 
Every effort should be made to bring out the patient's voluntary power. The 
deformities resulting may be improved by division of tendons and the appli- 
cation of splints. 1 

With regard to prognosis, it is well to give a carefully guarded opinion 
as to the future. Nearly all cases improve, and slight paralyses get quite 
well. Severe cases improve as years go on, but it is doubtful if they ever 
completely recover. In the majority of cases there is some mental feeble- 
ness, either a mere backwardness, or there may be decided idiocy. Some 
cases become epileptic. 

medullary Haemorrhage. — In speaking of haemophilia and of the 
haemorrhagic diathesis we have mentioned the fact that a cerebral haemor- 
rhage may occur in these conditions after a slight head injury. We have 
related such a case (p. 443;, and referred to some cases related by Steffen. 
The following case is a rare one belonging to the same category : 

Hccmophilia ; Medullary Hemorrhage. — Norah M., aged 3 years 10 months. Family 
history good. Father two years before suddenly lost the hearing in one ear, which was 
supposed to be due to haemorrhage. Patient had a sharp attack of scarlet fever, followed 
by glandular abcesses eighteen months ago. For the last year it had been noticed that 



1 Vide Willard, Trans. America?i Orthop. Assoc. September li 



Mcduhary Hemorrhage 



1 1 



she had exhibited a tendency to 'bruise,' purple spots appearing on the skin after the 
slightest injuries. She was a well-nourished child, but had always been difficult to feed. 
She was quite well till the morning of December 22, when she vomited and retched several 
times ; there was no history of a blow, but she had been to a children's part)- the evening 
before and had romped a good deal. The following day she was seen with Dr. Lawton ; 
was then noted she could not stand or sit, and when held up her head fell to the right side. 
There was slight paralysis of the left side of the face, including the orbicularis, but the eye 
could be closed ; the voice was weak and had a nasal twang ; on attempting to swallow, 
she coughed and spluttered as if some of the fluid entered the larynx. There was no 
cardiac murmur. Temperature 98°. December 24. — She had recovered some power in 
her legs, and she could sit up, but her head still fell over to the right side. It was noticed 
that her breathing was peculiar, the right side of the chest was moving excessively, while 
the left side was hardly moving at all ; rales were heard on both sides. December 25. — 
The swallowing was better, but it was clear the lungs were getting choked, as the rales were 
heard freely all over, the right side still moving more freely than left. Temperature 102 . 

The child became more and more dusky, the 
respirations increasing in number ; there was 
intense restlessness, and finally death from 
asphyxia on the evening of December 26. 
Post-mortem (head only). — No cerebral hae- 
morrhage except in the medulla, where it 





Fig. 109. — Posterior aspect of medulla showin 
discoloration over clot (nat. size). 



Fig. iic. - Transverse section of medulla 
through middle of olivary body showing 
laminated clot, compressing the right 
olivary nucleus, root of vagus, and nerve 
centres in floor of fourth ventricle. 
v. vagu-,. H, hypoglossal (nat. size). 

was noted that the right side of the medulla 
was swollen and discoloured (see fig. 109). On 
transverse section (after hardening) through 
the middle of the olivary bodies, a round lami- 
nated clot h inch in diameter was found, which 
had compressed the root of the right vagus, 
olivary nucleus, and also the nuclei in the 

lower part of the floor of the fourth ventricle (see fig. no). We are indebted to Dr. 

R. T. Williamson for microscopical examination of the clot. He found no evidence of 

any aneurismal sac. 

Embolism. — Among the various causes producing a paralysis of hemi- 
plegic distribution we must mention embolism. Embolism chiefly occurs in 
patients suffering from endocarditis, but also it appears to occur at times 
when there is no form of heart disease present, the thrombus appearing to form 
in the left auricle, or pulmonary veins. Embolism is perhaps most common 
m acute or malignant endocarditis ; this was so in the case recorded on 
page 409 (see fig. in). 

In the following case there was hemiplegia in consequence of a blocking 
of the middle cerebral artery, either from embolism or thrombosis : 

A boy of one year old, who had suffered since birth from marked cyanosis due to 
obstructive pulmonary disease (fig. 76 represents the heart of this case) and constant 



512 



Diseases of the Nervous System 



dyspepsia, was si night with vomiting and convulsions, followed by paralysis of 

the left arm and leg. When seen on the following morning, the head and neck 
tinned to the right side, the eyes were suffused and blinking, as if some foreign body was 
present, the right pupil was smaller than the left, but both acted to light ; the child was 
apparently quite blind ; there were no retinal haemorrhages, and the optic discs were 
normal. The face was drawn to the right side ; there was complete loss of power, and 
apparently loss of sensation, in both arm and leg of the left side ; no cry could be elicited 
on pinching or pricking the skin of either limb. The child was drowsy, but not uncon- 
scious, as he appeared at times to know his mother when in her lap. He was 
apparently deaf for the first twenty-four hours, though there was necessarily some diffi- 
culty in ascertaining this ; by the next day, though remaining blind, he knew the voices 
of his friends, and turned towards the direction of their voices ; it was clear, also, that he 
heard with both ears. Within a fortnight sight had returned, so that he could recognise 




Fig. in. — Horizontal Section of a Brain, showing patch of softening involving the left lenticular 
nucleus and anterior limb of the internal capsule. The lenticular-striate artery was plugged 
with an embolus and impervious. There was complete hemiplegia of the right side. (See p. 409.) 



his mother and his toys. His friends thought he regained his sight first in his right eye. 
By the end of six weeks sensation had returned, as far as could be judged, in the arm and 
leg, and some power was returning, as he moved both limbs on the left side. A week or 
two later he could hold a rattle in the left hand, but not raise it to his mouth; the leg 
showed a tendency to draw- up, and the knee reflex was much exaggerated. The child 
was quite intelligent and bright. Before death (seven months after seizure) much improve- 
ment had taken place ; the child could put out his hand, but there was some rigidity both 
in the arm and leg. Death occurred from bronchitis. Post-mortem. — On removing the 
brain, it was evident the right hemisphere had shrunk, being slightly smaller than the left, 
and that there was a large cyst (porencephalus), containing clear fluid, occupying the 
central part of the convexity of the right hemisphere (see fig. 112) ; the cyst corresponded 
with the distribution of the middle cerebral artery, excepting the branch to the inferior 
frontal convolution. The middle cerebral artery beyond its first branch was impervious, 



Embolism of the Brain 5 1 3 

and contained old clot. It was quite clear in this case that there had been thrombosis or 
embolism of the middle cerebral, with a subsequent softening of the area supplied by it ; 
a horizontal section showed that the internal capsule had been compressed. 

Xo emboli were found elsewhere ; there was no endocarditis of the mitral 
or aortic valves, but a much-contracted pulmonary artery and open foramen 
ovale. 

Dr. F. Taylor records a typical case of embolism following endocarditis : 

A boy of five years, two weeks after an attack of scarlet fever, was seized with hemi- 
plegia of the right side ; the urine was albuminous. Death occurred from diphtheria 
nine weeks afterwards ; embolism of the left middle cerebral artery, with extensive soften- 
ing of the left hemisphere, was found. There was endocarditis of the mitral valve. 

Abercrombie reports a case of a boy aged six years who was under treat- 
ment for diphtheria, and who on the fifteenth day was seized with general 
convulsions and left hemiplegia ; he died eleven days later. The middle 







Fig. 112. — Cyst formed by softening of brain substance, secondary to obstruction of the middle 
cerebral artery beyond tbe first branch (to inferior frontal convolution). The cyst wall has 
fallen in from escape of its contents. Child nineteen months old ; death seven months after 
onset of paralysis. 

cerebral artery was found plugged with an embolus ; infarcts were also found 
in the spleen and kidneys. There was no heart disease, and it was difficult 
to understand the source of the emboli, unless formed in the cavity of 
the heart or in the pulmonary veins ; this might be possible in paresis of the 
respiratory muscles and disturbed innervation of the heart, following 
diphtheria. Dr. Trevelyan reports a similar case to Dr. F. Taylors, in a 
girl aged eight years convalescent from diphtheria. 

A sudden hemiplegia may be caused by meningitis, the immediate cause 
being softening following thrombosis or embolism of the vessels ; the 
meningitis is usually tubercular. Thus a boy of six months of age, w r ho had 
been apparently healthy, suffered for a week or two from febrile disturbance, 
dyspepsia, and irritability, attributed not unnaturally by his friends to 
'teething : ; one evening at 8 p.m. he was convulsed, the right arm and leg 
twitching most : this was followed by right hemiplegia, including the face. 
At 3 A.M., when seen, the infant was unconscious, with contracted pupils, 
Cheyne-Stokes respiration, the face drawn to the left, the right arm and leg 

L L 



514 Diseases of the Nervous System 

completely powerless. Death took place three days later, the temperature 
rising in the meantime to 105 . The post-mortem showed a basal meningitis 
(tubercular), much fluid in the lateral ventricles, and softening of the left 
hemisphere and corpus striatum. 

Another lesion (this a rare one) giving rise to hemiplegia is an aneurism 
of the middle cerebral artery, the result of embolism in cases of acute 
endocarditis ; this was the case in a girl of nine years under our care who 
suffered from intermittent pyrexia and albuminuria, and in whom a loud 
systolic murmur was present. To these symptoms was added acute pain in 
the frontal region, coming on suddenly. An ophthalmoscopic examination 
showed large retinal haemorrhages surrounding the disc. A week later there 
was paresis of the right arm, no paralysis, but exaggerated tendon reflex of 
the right leg. Six weeks later she fell back unconscious while sitting up in 
bed : there was now right facial paralysis, and paralysis of the right leg. 
Death followed ten days later. An aneurism the size of a small walnut, 
on the second branch (to the ascending frontal convolution), near its origin 
from the trunk of the left middle cerebral artery, which had ruptured and 
given rise to meningeal haemorrhage, was found post mortem. 

Thrombosis of the Cerebral Sinuses and Veins. — Thrombosis of the 
cerebral sinuses or veins is not a common occurrence during infancy and 
childhood. It may occur in the superior longitudinal, lateral, or cavernous 
sinus. It is most likely to occur in extreme anaemia, after exhausting 
diseases as acute diarrhoea, where the force of the heart is weakened and a 
stasis or slowing of the venous current takes place. Thrombosis may also 
occur in the surface veins under similar circumstances, or the clotting in the 
veins may be the result of meningitis. The immediate result of the obstruc- 
tion to the veins or sinuses is to distend the venous branches behind the 
obstruction to their utmost capacity, and possibly also to give rise to puncti- 
form haemorrhage and softening of the brain. Thrombosis of venous 
channels may take place in the neighbourhood of some inflammation, as in 
otitis, and pyaemia may result. 

Symptoms. — There is a condition of great exhaustion and pallor, and to 
these are added cerebral symptoms and venous obstruction. The fontanelle 
is tense, the veins of the forehead, nose, and face are distended ; there is 
epistaxis and probably convulsions ; perhaps, also, rigidity and retraction of 
the neck, and paralysis of one or more extremities. In making a diagnosis, 
it must be remembered that the so-called ' false-hydrocephaloid ' or cerebral 
anaemia gives rise to convulsions, stupor, and coma, and is infinitely more 
common than thrombosis. We are only justified in diagnosing the latter 
when there is distension of the veins of the face and forehead, or some 
definite paralysis. Thrombosis of the cavernous sinus is most likely to occur 
in some local lesion, as a tumour, as a periosteal sarcoma of the sphenoid 
bone, or caries ; the eyeball is prominent, there is oedema of the eyelids and 
distension of the veins of the forehead. 

Treatment. — The action of the heart must be strengthened by stimulants 
and digitalis, and the tendency to exhaustion and syncope must be combated 
by beef tea and highly concentrated forms of nourishment. The patient 
should be kept in the prone position as much as possible, with the shoulders 
and head raised. The prognosis is necessarily extremely grave. 



5*5 



CHAPTER XXIV 

DISEASES OF THE NERVOUS SYSTEM— continued 

Chorea 

CHOREA is a disease which occurs chiefly in children between the ages of 
six and fifteen years, and is characterised by irregular spasms of the volun- 
tary muscles, and in some cases by paresis of the extremities and mental 
weakness. 

^Etiology. — Chorea can hardly be said to be hereditary, but undoubtedly 
a tendency to neuroses or ' weak nerves ' runs in families, and instances 
might be adduced of emotional parents having children who suffer from 
chorea ; moreover, it is a common experience to find several sisters or brothers 
suffering from chorea, or perhaps one or more are neurotic or hysterical. 

Chorea is not common before the age of six years, and after the age of 
fifteen years the liability to attacks becomes very much less. It is more 
common in girls than boys, in this respect resembling hysteria and other 
emotional diseases. Analysing 633 cases which have attended at the Chil- 
dren's Hospital, we find that 454 were girls and 179 were boys, giving a 
proportion of five girls to two boys ; these figures closely correspond to the 
statistics collected by other writers. 1 In 252 cases the ages of the patients 
were analysed, giving the following result : 

Under six years . . . 15=3 boys and 12 girls 

Between six and ten years . . 102 = 35 boys and 67 girls 

Between ten and fifteen years . 135 =44 boys and 91 girls 

The youngest child was a girl of four years of age. 

The children most apt to suffer are the nervous and excitable, those who 
are easily frightened, especially if they are suffering from ill-health, the result 
of unfavourable life- conditions or rapid growth. 

By far the commonest exciting cause is a fright ; in 38 cases out of 252 
there was a definite history of the patient being frightened, the symptoms 
following in some cases next day, in others within a few days or a week. 
The causes of the fright were various : in one case, that of a boy, the symptoms 
followed three days after seeing a ' man with his throat cut ; ; sometimes the 
attack was ascribed to a ' dog having flown at the child/ or the patient 
was ' frightened by a policeman,' or the child had been caned by the school- 
mistress or had had a fall downstairs. In such histories there is often some- 
thing it is necessary to discount : probably the scoldings at school were the 

1 See Fagge's Principles and Practice of Medicine, edited by Pye-Smith. 2nd edit. 

I.L2 



5 1 6 Diseases of the Nervous System 

consequence and not the cause of the chorea ; but, on the other hand, it is 
certain that chorea may follow within a few hours of a serious shock to the 
nervous system. 

Mental strain, as working hard for an examination, in some cases appears 
to excite an attack ; this has occurred too often in our experience to be 
attributed to any mere coincidence. Given a fast-growing and delicate girl 
of excitable disposition and not too well fed, who is at school for many hours 
during the day, and has to divide her attention between home lessons and 
various domestic duties, so that she becomes little else than a drudge, we 
can hardly be surprised if she suffers from a nervous breakdown. ' School- 
made chorea,' as Dr. Sturges calls it, is not by any means confined to the 
poorer classes, and, although among the better-to-do classes there is no 
question of poor food and household drudgery, yet there is often much 
forcing exercised to induce a girl, of perhaps delicate health, to keep pace 
with, or run ahead of, her stronger and more robust class-mates. 

In some instances children who are convalescent from various depressing 
diseases, such as acute rheumatism, enteric fever, or scarlet fever, are attacked 
with chorea. Rheumatism excepted, enteric fever in our experience more 
often than any other disease predisposes to chorea ; other nervous dis- 
orders, such as dementia, mania, and aphasia, are not uncommon after 
enteric, and are no doubt due, as is also the chorea, to the anaemia and 
exhaustion caused by the long drain on the system during the disease. For 
the connection of rheumatism with chorea, see p. 519. 

Heart, disease in some instances precedes the attack of chorea, or, in other 
words, chorea makes its appearance in children suffering from cardiac disease. 

It sometimes happens that a source of irritation in some part of the body 
is the exciting cause of an attack of chorea ; thus we have seen a temporary 
chorea occasioned by suppuration in the middle ear, the choreic movements 
ceasing when the discharge made its appearance. In other cases it happens 
that chorea is an early symptom in pericarditis — this we have also seen ; in 
one case, in a little girl of four years, choreic movements preceded by a few 
days the physical signs of a pericarditis which proved fatal. We cannot 
help thinking that in such a case the chorea was symptomatic of the pericar- 
ditis, the latter being the primary lesion, rather than that the heart lesion was 
secondary to the chorea. 

Imitation in some cases seems to be a factor in the production of chorea. 
On one occasion five cases occurred in a girls' school immediately after the 
admission of a child suffering from chorea ; in such cases, perhaps, it may 
not be imitation so much as fright at seeing others affected, as Gowers 
suggests. We have never known children in the same ward to become 
choreic in consequence of a bad case being admitted, but we have seen 
cases of chorea apparently made worse by association with a bad case. 

Symptoms. — Most of those who suffer from chorea are in some way or 
other weakly, or at least not in robust health ; they are often anaemic, rapidly 
growing girl§; Not infrequently, it occurs in girls who have gone out to 
service, and who are undertaking work which is beyond their strength. Often 
the first symptoms are a loss of control over the muscles, especially the 
flexors and extensors of the fingers and wrists, and a want of precision in 
the movements of the hands. The patient drops cups and saucers on the floor, 



Chorea 517 

is unable to do needlework, fumbles sadly when she attempts to tie a piece 
of string, or spills her food when she passes it to her mouth. Sometimes, 
especially in younger children, the first thing noticed is that she ' makes 
faces,' her mouth screwing up so as to make grotesque grimaces, while she 
fidgets with her fingers, and when she attempts to dress herself makes use- 
less, clumsy, ineffectual movements. All this may go on for many days, 
perhaps weeks, without the friends thinking the child is really ill, and perhaps 
she gets scolded, both at home and at school, for her clumsy ways and 
inattention to her work. It is needless to say the scoldings do no good. Sooner 
or later the movements become too obvious to escape attention ; indeed, it 
is apparent to everyone that something is wrong. These movements, as 
Dr. Sturges points out, are much more vigorous in the upper part of the body 
than the lower, the hands suffering most of all. The fingers are opened and 
shut, the extensor and flexor muscles being constantly worked ; the arm is 
passed behind the back, then brought to the front ; if asked to shake hands, 
it is thrust rapidly forward, being directed with difficulty to the hand to be 
grasped. The tongue is protruded with a jerk, and perhaps drawn back 
again in a moment with a quick movement. The muscles of the face are 
frequently spasmodically contracted, so that the queer grinning grimaces are 
constantly being made. The muscles of the neck are frequently contracted 
and relaxed, so that the head is moved from side to side or rotated. When 
the child walks, the feet join in the spasmodic movements, so that the gait 
is altered, the legs being thrown forward quickly, or if the patient stands the 
feet are restless, being shifted about from place to place. When the patient 
is at rest in bed she will lie still if not -disturbed, but directly she is interfered 
with — as, for instance, to examine the chest — the movements begin, the hands, 
face, and trunk muscles being thrown into a state of clonic spasm. The 
muscles of respiration do not escape : the child takes a deep sighing inspira- 
tion, then perhaps there is a series of shallow irregular respirations. The 
irregular respirations may affect the pulse, so that it is irregular and inter- 
mittent. The movements cease during sleep, though sleep is not readily 
obtained ; indeed, in the worst cases the patient only sleeps when under the 
influence of chloral or opium, which has to be freely given in order to secure 
rest. In the milder cases the movement may be confined to one side ; this, 
however, is never the case when the movements are severe, though it is very 
common to have the clonic spasms more vigorous on one side than the other. 
A hemichorea, in which the movements are vigorous and entirely confined 
to one arm or leg, is probably due to some organic cerebral disease. 

The temperature is usually normal throughout, sometimes subnormal ; 
if there is any fever, peri-endocarditis or rheumatism should be suspected. 
In the most severe cases the temperature may be raised a degree or two. 

There is often marked paresis of an arm or leg, far more commonly the 
former ; not only is the grasp feeble, but the arm is weak and powerless, 
though complete, or indeed well-marked, paralysis does not occur. This 
paresis of an arm is sometimes the most prominent feature iif the case, but 
in all cases more or less of clonic spasm may be detected in the fingers or in 
the facial muscles. These cases have been spoken of as ' paralytic chorea.' 

The electric irritability of the muscles in cases of hemichorea has been 
studied by several observers, most recently by Gowers, cases of hemichorea 



5 1 8 Diseases of the Nervous System 

being selected on account of the possibility of comparing the muscles of one 
side with the other. In some cases no difference can be detected, but in 
others there has been noted an increase of irritability on the affected side, 
the muscles contracting with a weaker faradic and also voltaic current than 
those on the unaffected side. 

The speech is affected, in some cases from the muscles of the tongue, 
jaw, and larynx not being under sufficient control. In other cases the mental 
weakness frequently present may be the cause. Headaches are often com- 
plained of; sometimes, especially in cases of 'hysterical chorea,' there is 
hyperesthesia or anaesthesia. 

Optic neuritis has been observed by Gowers, slight in degree in some 
cases ; in one case there was a sufficient degree to make it comparable to 
the neuritis seen in a case of cerebral tumour. In the vast majority of cases 
there are no ophthalmoscopic changes. 

The mental state is often peculiar. There is a vacant, listless expression 
on the face, in many cases a dulness of comprehension. The child may 
cry on the slightest provocation. There may be actual dementia, or, on the 
other hand, maniacal excitement. 

In the worst cases the movements are severe : the child constantly 
wriggles about, and the arms and legs move sufficiently violently to throw the 
patient out of bed. The constant movements of the limbs chafe the skin on 
the extensor surfaces, so that unhealthy looking sores may result. We have 
seen such in a fatal case become actually gangrenous before death. The 
patient is sleepless, and becomes anaemic and completely exhausted. Death, 
however, may not result from actual exhaustion, it may occur in consequence 
of pyaemia or pericarditis. Among over 634 cases there were five deaths, but 
one of these died, not from chorea, but from an intercurrent tubercular 
meningitis. All five cases were in girls ; indeed, fatal cases in boys are very 
rare. Dr. Fagge relates the case of a boy who died in nine days, and another 
boy of twelve years who died from obstructed breathing due to glossitis, the 
tongue having been severely bitten. 

The following is the history of a fatal case of chorea : 

Chorea, Endocarditis, Death. — Maggie May B., aged 10 years. Four members of 
the same family have recently suffered from sore throats and fever due to drain smells at 
the back of the house. No history of rheumatism or previous attack of chorea. Patient 
has been attended at home by Dr. V. Brown. She has had severe chorea at home for 
two weeks. Admitted February 27, 1891. The choreic movements are moderately severe ; 
she cannot feed herself; the heart's action is irregular, but there is no bruit; there is 
incontinence of urine ; sordes on her lips and teeth ; temperature, 98°-ioo° ; sleeps badly. 
March 2. — Has been taking bromide and chloral, is quieter, and the movements are 
less ; temperature, 96 -c.8°. March 9. — Still improving, no bruit heard, sleeps better. 
March n.— The temperature has gone up to 104° F. this afternoon ; the movements are 
now very violent ; chloroform has been given to quiet the excessive movements. Bruit 
heard for the first time at the apex. Nepenthe in 10-minim doses seems to excite ; chloral 
appears to answer better. March 16. — Has been taking bromide, chloral, and hyoscya- 
mus ; is quieter, but takes food with difficulty ; temperature, 97 c -ioi°. Extensor surfaces 
of the arm are very rough and sore from friction ; there is swelling of the right parotid. 
March 19. — Much worse to-day. Respiration, Cheyne-Stokes. Died in the evening. 

Post-mortem. — Skin covering elbows and wrists roughened and abraded, ulcer on ball 
of thumb, ulcer over styloid process of radius and lower end of ulna ; both ears are 
abraded ; hair at back of head worn off; knuckles abraded. Much swelling of right 



Chorea 519 

parotid. Lungs.— Old adhesions round left ; right upper lobe dark red, solid behind, 
and sinks in water ; anterior edge emphysematous ; lower lobe semi-solid. There are 
patches of consolidation in the left lung ; the back of the upper lobe is engorged. Heart 
(6£ oz.) is firmly contracted, especially left ventricle. Mitral valves show recent endo- 
carditis, the edges being beaded (see fig. 79, which was drawn from this case) ; other 
valves healthy. No dilatation or hypertrophy. Intestines congested, Peyer's patches 
swollen, slightly abraded in places. Liver (44 oz. ) enlarged and congested. Spleen 
(45 oz.) large and soft. Kidneys congested. Brain. — Veins on surface full. Arachnoid 
membrane opaque and cloudy, excess of subarachnoid fluid. There is a patch of what 
appears to be lymph on the convex surface. In the Sylvian fissure the arachnoid is 
especially opaque. The brain substance is firm, the capillaries are congested. 

Chorea is a chronic disease lasting for many weeks, often many months, 
but it is usually not equally severe throughout this period. Ten weeks is 
often stated to be the average ; it certainly is often much longer. Relapses 
are exceedingly common ; it is not uncommon for children to have three to 
five attacks, but the tendency passes off after puberty. 

Coiiiplications. — In the majority of cases of chorea the heart is in some 
way or other affected. In some cases chorea apparently supervenes in 
children who are suffering from chronic heart disease ; in a few cases it 
appears to be brought on by an attack of pericarditis, but in the majority of 
cases the heart complication comes on during the course of an attack of 
chorea. Out of 252 cases of chorea, nothing abnormal was noted in the 
heart's action in 79 ; in 54 there was irregularity or reduplication of the 
sounds ; in 119, bruits, mostly heard at the apex more loudly than at the base, 
were detected. Some of these bruits were, no doubt, anaemic, inasmuch as 
they were present only at the base ; it is seldom, however, possible to say 
dogmatically that a bruit heard during the course of chorea is simply hasmic, 
and it is necessary to have the patient under observation for a long period 
during convalescence before we are in a position to say if a so-called hasmic 
bruit is due to organic disease or not. It is well also to remember that 
endocarditis may occur and yet no bruit be produced ; thus we have 
sometimes failed to detect bruits in cases of chorea, but some months after- 
wards have noticed undoubted organic murmurs. Both mitral and aortic 
valves may be affected, though the former are far more commonly affected 
than the latter ; while many of those in whom bruits are heard during chorea 
have suffered from rheumatism, this is by no means the case with all. 

Acute or sub-acute rheumatism was associated with chorea in 46 out 
of 252 cases, while 20 more, according to their friends' account, suffered from 
' rheumatic pains.' Statistics with regard to the association of chorea and 
rheumatism vary considerably, but this is hardly surprising, inasmuch as we 
are largely dependent upon the histories given by friends, and their ideas 
concerning rheumatism are apt to be vague ; moreover, the symptoms of 
rheumatism are often less well-marked in children than in adults, and 
rheumatic attacks may be easily overlooked, or at least may not be recog- 
nised as rheumatic. The association of rheumatism and chorea is undoubted, 
and cannot be a mere coincidence ; not only do we see children suffering 
from chorea attacked with rheumatism, and vice versa, but not infrequently 
we see a sister suffering from chorea and a brother from rheumatism, or 
attacks of chorea and rheumatism alternating in the same individual. 
Rheumatic nodules are present in a few cases. 



520 Diseases of the Nervous System 

The following- case illustrates the association of chorea with rheumatism : 

A Case of Chorea attended by Paresis and loss of Speech for eighty-one days, and com- 
plicated with Peri-Endocarditis and many Fibrous Nodules. Death after 8i months' 
illness. — Edith M. N. , aged 9 years, the daughter of a surgeon, was fairly strong and 
enjoyed good health till early in June 1889, when it was noticed she had 
decided choreic movements; for three or four weeks previous to this some premonitory 
symptoms, such as excessive fidgetiness, had made their appearance. In the previous 
September, eight months before the beginning of the illness, she received a severe fright 
when away from home, and since then had been subject to peculiar nervous attacks. 
There is a strong rheumatic history in both parents. During the early weeks of June the 
choreic movements steadily increased, and were most marked in the face and right side of 
the body. Her speech was affected, and on July 19 she lost the power of speech, a con- 
dition which lasted for eighty-one days. About this date she lost control over her limbs ; 
any attempt at voluntary movement rendered the involuntary movements stronger and 
more erratic. She was unable to change her position in bed, and, indeed, on one occasion 
was nearly suffocated by slipping down the bedclothes and being unable to extricate her- 
self. On the same date several joints became tender, being most marked in the right 
elbow and wrist. During the next few days the movements became more violent, all 
the limbs being tossed about, the head jerked and banged from side to side, and the 
features constantly contorted. She was fed with difficulty, on account of the movements 
of the muscles of mastication and a difficulty of swallowing. Early in July a mitral 
regurgitant bruit was detected, rheumatic pains were constant, the fibrous nodules made 
their appearance. The ' rheumatic ' pains varied, sometimes the joints were tender, at 
other times there were shooting pains down the legs ; the first nodule noticed was over one 
of the spinous processes of the cervical vertebrae. These nodules were followed by many 
others, which made their appearance during the succeeding two or three months. At one 
time there were at least 200 present, being situated on the scalp, borders of the scapulae, 
along the ribs, tendons of the hands and feet. There was one present over each spinous 
process, presenting an appearance resembling Dr. Cheadle's illustration in the Lancet, 
May 4, 1889. They varied in size from a pea to a large filbert, and in some places, 
especially on the back of the head, they presented an almost bony hardness. The choreic 
movements at this time were exceedingly severe, continuing both night and day, the 
patient obtaining very little rest. The tongue and mucous membrane of the cheeks and 
lips were bitten, and troublesome ulcers resulted. The lower jaw was retracted, appa- 
rently from spasm of the muscles, so that the lower incisors closed inside the upper incisors. 
There were frequent involuntary movements of the bowels and bladder. On July 12 a 
friction sound was heard over the cardiac region, followed by a large effusion into the 
pericardium, with a weak and rapid pulse. By the end of July the fluid in the pericar- 
dium had diminished in quantity and the dyspnoea was less urgent than it had been. The 
choreic movements were less violent, but a paresis of the extensors of the fingers and an 
over-action of the flexors was noted, so that a ball of cotton wool had to be "kept in the 
palms of the hands to protect the skin from being injured by the nails. Another note- 
worthy point was the extreme retraction of the jaw. The emaciation and exhaustion had 
now become extreme. In August another attack of pericarditis occurred, with effusion, 
and as the fluid became absorbed the systolic murmur noted a month before became 
louder ; there was also a thrill and a distinct presystolic bruit. The condition remained 
much the same during August and the early part of September ; at this time she was 
kindly seen by Dr. W. B. Cheadle, of London. On the evening of September 8 the power 
of speech suddenly returned, and from this time she was able to converse with her friends. 
Later she suffered from several fresh attacks of rheumatic pains and violent attacks of pain 
over the precordial region. During the latter part of September and during the next two 
months gradual improvement took place ; the movements ceased, the paresis of the limbs 
disappeared, and she was able to walk with help ; but the heart evidently became more 
and more enlarged, and the systolic bruit more marked. In January signs of cardiac 
failure set in ; there was enlargement of the liver, great anaemia, dyspepsia, and dyspnoea on 
exertion. There were also frequent attacks of severe cardiac neuralgia, the pain being 
referred to the precordial region, and there was a sense of constriction round the waist. 



CJiorea S 21 

Early in February oedema of the feet came on, while the attacks of cardiac pain were most 
distressing, and continued till her death on February 19, the illness having lasted nearly 
nine months in all. 

This case illustrates in a remarkable manner the close association between 
chorea and the rheumatic state, and the damage which the heart may suffer 
in the young without the patient suffering from a typical attack of articular 
inflammation. Apart from the severe chorea from which the patient suffered, 
there was a continuance of the ' rheumatic state ; for several months, during 
which time there were joint tenderness, shooting pains, acid perspirations, 
continuous crops of 'fibrous nodules,' patches of erythema, and repeated 
attacks of carditis. It is evident that the latter was chiefly instrumental in 
bringing about the fatal termination, for it was clear there was not only a 
damaged mitral valve", but also a dilated heart. 

Of what prognostic importance were the large crops of fibrous nodules ? 
We may certainly say they pointed to the intensity of the c rheumatic ; state, 
and the consequent probability of recurrent attacks of peri-endocarditis. 
It is worthy of note that these nodules were mostly situated over prominent 
parts, and where, in the choreic state of the patient, friction would be most 
intense. Thus they were present at the back of the head, over the spinous 
processes, and along the edges of the scapula. In the rheumatic state, 
as Dr. Cheadle insists, there is a special liability to irritative lesions of the 
fibrous tissues ; this is seen in the nodules — which are caused by a prolifera- 
tion, and cell-infiltration of the fibrous tissue — and in the endocardial, peri- 
cardial, and pleural inflammations. If, as he believes, there is a close re- 
lationship between the fibrous nodules and peri-endocarditis, the significance 
of the occurrence of nodules cannot be overrated. Perhaps the most inter- 
esting features in the case were those connected with the nervous system. 
For nearly three months the patient did not speak and the only sounds made 
consisted of a sort of ' grunt.' She was perfectly sensible and rational, 
and would try to nod or shake her head, but any attempt at speaking, 
especially when the chorea was at its worst, made the involuntary move- 
ments of the face and neck more violent. The cause of the loss of speech 
was doubtless due to a loss of control over the muscles of the tongue and 
lips. This was also manifested in the difficulty of masticating food. The 
power of speech entirely returned, and was retained up to the time of her 
death. Another peculiar symptom was the retraction of the jaw, which was 
well marked, apparently being caused by over-action of the retractor muscles. 
In the later stages of the choreic attack, the weakness of the arms and the 
over-action of the flexors of the fingers were well seen. The hands were 
tightly clenched, and any attempt to force them open gave pain and brought 
on a more convulsive action of the flexors of the fingers. There was also 
some rigidity of the legs, with pointing of the toes. At this period there was 
much wasting of the muscles, with a certain amount of tenderness on pressure 
over them. 

A paresis of one arm not infrequently takes place in chorea ; such cases 
having been described as paralytic chorea. It consists in weakness rather 
than paralysis, and not infrequently precedes the other symptoms of chorea. 
A peripheral neuritis in rare cases appears to follow chorea, as it does 
also rheumatic attacks, the principal phenomena being muscular w-asting 



522 Diseases of the Nervous System 

and paresis, indefinite pains such as ' pins and needles,' and in some instances 
anaesthesia. 

In some cases there is sufficient excitement of the brain to merit the 
name of maniacal chorea or chorea insaniens. This condition is most 
common at or about puberty. There may be violent delirium and excite- 
ment, so that the patient has to be controlled by her attendants, the attacks 
resembling acute mania. Often these attacks are closely allied to, or resemble, 
hysteria. The following case appears to have been one of this kind : 

Maniacal Chorea ; Hysteria. — The patient was a girl of fourteen years of age ; both 
her sister and herself had chorea a year and a half before the present attack, which lasted 
for some time, and for which she was treated in the Derby Infirmary. She was re-admitted 
with choreic movements of moderate intensity, but they were readily controlled by the will, 
and she was perfectly rational. She got worse, the movements- being more violent ; there 
was difficulty of speech, she became extremely emotional and at times maniacal. When 
she was moved— as, for instance, when her bed was made — she would struggle and run 
her nails into the attendants. Two months after admission the knees became semi-flexed 
and rigid, and there was incontinence of urine and feces. She was so troublesome that 
she was sent home after about three months in hospital. L Some time after she was 
admitted to the Children's Hospital. At this time she had sordes on her lips and teeth, 
she was much emaciated ; both knees were semiflexed and rigid, the hips were semi- 
flexed and rigid ; the patellar reflex could not be obtained on account of the excessive 
rigidity. There were slight choreic movements of the arms and face ; she passed her 
urine and feces into bed. She was extremely emotional, and there was some hyper- 
esthesia, especially about the joints and muscles. She gradually began to improve in a 
week or two, having more control over the sphincters, and the legs became less rigid and 
she gained flesh. A fortnight after admission the bedsores had healed, and she was less 
emotional. In a month she could walk with help, and in three months she was discharged 
quite well. 

In this case there seems to have been aggravated hysteria associated 
with chorea, although at one time the girl looked very much as if she was 
suffering from organic brain disease. The emaciation, bedsores, and rigid 
legs seemed to point to an organic lesion ; this was, however, negatived by 
her complete recovery. 

In some rare cases instead of paresis there is muscular spasm, which may 
persist for some time after the choreic movements have disappeared. The 
following case illustrates this : 

Chorea ; Muscular Spasm. — A boy, aged \oh years, was admitted to the Children's 
Hospital suffering from chorea, which was attributed to a fright, he having seen a ' ghost 
at a show\' Three sisters had also suffered from chorea, one having died during an attack. 
His attack was a moderate one ; no bruit was heard, there was some paresis of his right 
leg. He was discharged in a month's time quite well. He was re-admitted two months 
later, the choreic movements being pretty much confined to the right arm, which was 
markedly weak : the right knee joint and ankle were rigid, the muscles being in a state of 
spasm ; there was no pain or tenderness. There was a systolic bruit at the apex. He was 
discharged in six weeks ; the choreic movements had disappeared, but the spasm in the 
right leg persisted. He had another attack of chorea eighteen months afterwards ; before 
this occurred, the muscular spasm had entirely disappeared. 

Hemichorea — In many cases, as already pointed out,. the movements 
are confined to one side of the body, or at all events they are more marked 
on one side than the other. Hemichorea is in some instances post-hemi- 

1 These notes were kindly furnished by Dr. W. Benthall, of Derby. 



Chorea 523 

plegic, following some months or more after the hemiplegia, when contrac- 
tures are present, as in the case of cerebral tumours situated near and 
involving the internal capsule or pyramidal tracts : choreiform movements 
may take place on the opposite side. In hemichorea symptomatic of brain 
disease the movements are vigorous and grotesque, the ringers, hands, feet, 
and extremities being twisted and jerked about. In one of our cases, in a 
boy of five years of age, who had a cheesy tumour in the right optic thalamus, 
at first sight the child appeared to be affected with the ordinary form of 
chorea. His left arm was in constant movement, the result of short, irregular, 
jerky contractions of the muscles of the forearm and arm, following one 
another with great rapidity, and closely resembling those seen in a severe 
case of chorea. When the boy was at rest the arm was quiet, only a sort of 
fumbling movement of his hand being noticed, but on asking him to sit up 
or give his hand, vigorous, almost violent, movements began again. Some of 
the movements were produced by all the muscles of the arm, yet some of the 
muscles acted more continuously and powerfully than others, so that the 
arm tended to be held to the side and more or less behind, while the fore- 
arm was pronated and the wrist flexed, the fingers being in continual move- 
ment. This condition of hemichorea differs from 'athetosis' or 'mobile' 
spasm already described (p. 556). 

Morbid Anatomy. — Various minute changes have been described in the 
brain in fatal cases of chorea, but it is quite certain that no constant and 
invariable lesion has been discovered. Embolism and thrombosis of the 
minute vessels of the cortex and basal ganglia have been described ; minute 
spots of softening, changes in the nerve cells, and enlarged perivascular 
spaces have also been found. We cannot say that any of these observations 
throw any light on the morbid anatomy of the disease, especially when we 
remember that on various occasions competent observers have found 
nothing of importance in their examination of the brain and spinal cord in 
fatal cases. Many of the changes described are no doubt secondary, the 
result of hyperaemia of the nervous centres. 

The frequent association of chorea with rheumatism and endocarditis 
suggested to Kirkes the idea that chorea was the result of minute embolism 
of the brain by fragments of fibrin washed off the mitral valves. This 
hypothesis, however, is quite inadequate to explain the phenomena presented 
by the disease ; thus chorea has followed within a few hours of a sudden 
fright, and moreover fatal cases have been recorded (though rarely) in which 
no endocarditis has been found. Embolism will not explain those cases of 
' reflex chorea ' in which the exciting cause is an acute otitis, or when chorea 
follows some injury or accompanies pregnancy ; we find that pericarditis, and 
perhaps endocarditis, act as exciting causes operating through the nervous 
system, just in the same way as some gastric-intestinal irritation may be the 
exciting cause of convulsions in infants. 

In considering the pathology of chorea we must take into account the 
associations of chorea, though it cannot be said they help us much in coming 
to a conclusion. Chorea is associated, on the one hand, with rheumatism 
and endocarditis, and on the other with hysteria and mania : the former 
association would suggest a blood-change, the latter simply a functional 
disturbance of the nervous system. Patholcgists in formulating their 



5-4 Diseases of the Nervous System 

theories have leaned either to the one or to the other. Sometimes chorea 
has been explained as secondary to endocarditis, as a result of capillary 
embolism, or as the result of a 'rheumatic' condition of blood, in which 
some chemical poison has been present in the blood which has a specific 
action on the nervous system. At other times chorea has been looked upon 
as an emotional disease, and, like hysteria, a purely functional disease, or, as 
it has been termed, an ' insanity of the muscles' or motor region of the brain, 
just as mania or other forms of insanity affect the seat of the mind. 

There has been also much difference of opinion with regard to the seat 
of the disease ; it has been placed in the spinal cord, basal ganglia, and 
cortex of the brain. The fact that the face is usually affected, and that more- 
over the choreic movements are frequently one-sided, would almost certainly 
point to the seat of the disease being within the cranium. The tendency of 
recent researches in physiology has been to deprive the corpus striatum of its 
alleged function as an originator or co-ordinator of motor influences, and to 
assert that it has little or nothing to do with the discharges of motor force. 
On the other hand, there is strong reason to believe that the choreic move- 
ments are the result of irregular discharges from the motor region of the 
cortex ; for the time being the will or the inhibitory influence of the frontal 
regions is in abeyance, and irregular purposeless discharges are given out 
from the cells in the motor region of the cortex. There is much reason to 
believe that the functions of the cortex are impaired in chorea, as shown not 
only by the spasmodic movements, but also by the paresis which sometimes 
occurs, and the mental dulness and emotional disturbance so often present. 
It can easily be understood that if there is impaired nutrition of the nerve 
centres, a sudden fright, or an irritation at some distant part, may start the 
irregular discharges from the cortex, which it may soon be beyond the power 
of the will to control. 

With regard to the cardiac complications found in fatal cases we cannot 
do better than quote Dr. Sturges, who sums up as follows : ' Vegetations, new 
or old, on the auricular surface of the mitral valves, with or without similar 
deposits on the aortic valves, and sometimes with pericarditis, are met with 
in the great majority of cases dying of, or with, or shortly after, chorea. 
This condition, however, does not, as a rule, contribute directly to the fatal 
issue ; it is found equally among those that die with and those that die of 
chorea, and in some of the most marked and typical cases of fatal chorea 
the valves of the heart have been found absolutely healthy.' 

Diagnosis.— This is not usually difficult, though it must always be borne 
in mind that the choreic movements present may be symptomatic of some 
serious brain lesion, or of some distinct disturbing influence, such as 
pericarditis. We have seen on one or tw T o occasions, in girls about puberty, 
choreic movements followed by emotional disturbance and paresis of limbs, 
attributed not unnaturally to hysteria, where the onset of optic neuritis and 
amblyopia has made it clear that the case was really one of cerebral 
tumour. We have seen also the onset of chorea in a girl of four years followed 
in a week by pericarditis and death in a few days. 

Any brain lesion which presses upon the pyramidal tract may give rise to 
movements similar to chorea ; we have several times seen this in cheesy 
tumours of the optic thalamus which compressed the internal capsule ; in 



Chorea 525 

such cases a ' hemichorea ' is produced (see p. 522). It must be borne in 
mind that in true chorea, if at all intense, the movements are general, though 
perhaps worse on one side than on the other, but they are never confined to 
one side, as in the case of cerebral tumour. 

In some of the special varieties of the disease the diagnosis may be 
difficult ; thus in the case related (p. 522), where there was contraction of the 
limbs and bedsores, one might readily assume that chronic meningitis or 
other cerebral lesion was present. In a case under our care, where tuber- 
cular meningitis supervened in the course of chorea, the diagnosis was un- 
certain for a few days. The presence of optic neuritis would strongly 
point to organic disease, though, as already stated, Gowers has observed 
optic neuritis in a case of chorea. In cases of paralytic chorea the chief 
symptom may be simply paresis of one arm ; but usually a slight exam- 
ination will detect short clonic spasms, either in the affected arm or 
elsewhere. 

Prog?iosis. — Recovery follows in the vast majority of instances. The 
principal danger is from some heart complication, as pericarditis, and from 
exhaustion in consequence of the violence of the movements, want of sleep, 
and nourishment. The more severe the case, the longer will be its duration. 
Maniacal and hysterical choreic cases are usually very chronic. 

Treatment. — The most important element in the treatment of chorea is 
rest. It is necessary to secure for a patient suffering from chorea complete 
rest for the body, and complete absence of excitement of all kinds. In all 
but the mild cases it is well to begin the treatment by keeping the patient 
for a few days or a week in bed completely at rest. We must bear in mind 
that voluntary movements of all kinds (in severe cases at least) make the 
involuntary movements more marked and ' more completely beyond the 
control of the will. On the other hand, the movements cease during sleep, 
and the more quiet a patient can be kept, the better chance there is of a 
better nutrition of the body and the nervous centres. Any excitement or 
mental effort is certain also to make matters worse, so that all forms of 
mental work must be avoided, while the surroundings of the patient must be 
made as agreeable as possible. When the movements are severe, so that 
the patient cannot sleep, some narcotic must be prescribed, and of remedies 
of this class chloral is probably the best, but it must be given in full doses 
to be of use. Ten or fifteen grains may be given, and- repeated in four hours 
if the restlessness continues. Bromide of potassium may be combined with 
the chloral, though most agree that chloral is more useful than the bromide. 
Morphia seems at times to add to the excitement present, though in some cases 
it acts better than chloral. In the case recorded on p. 520 (girl aged nine 
years), chloral and bromide entirely failed. Nepenthe in 10-minim doses 
gave sleep : later in the disease as much as 30 minims, and on one occasion 
70 minims, were given in one night. This was, of course, only after a toler- 
ance of the drug had been established. Inhalations of chloroform are often 
useful to get the patient off to sleep. Great care must be taken to prevent 
the patient from injuring" herself by tumbling out of bed, and it may be 
necessary to protect the limbs by wrapping them up in cotton wool, or to 
surround them with some soft material ; or padded boards may be placed on 
each side of the bed, or a mattress may be placed on the floor. The patient 



526 Diseases of the Nervous System 

should be given a fair amount of liquid nourishment, and also stimulants. 
Frequent spongings are of great value in getting the skin to act and calming 
the patient. 

Even in the less severe cases of chorea it is well to confine the patient to 
bed for a week or two in the early stages ; the movements are always less 
when the child is at rest in bed, and these means are almost certain to shorten 
the duration of the attack. When improvement occurs the patient may be 
allowed to get up for a few hours a day and be taken out into the fresh 
air, but too much exercise should be prevented. 

The drug which is most used at the present time is arsenic ; sulphate or 
oxide of zinc, cannabis indica, iron, Calabar bean, and conium have also been 
used. We confess to some scepticism with regard to the value of medicines 
in chorea, and feel sure they occupy only a subsidiary place in treatment. 
Arsenic is certainly of use in the dyspeptic conditions which so often 
accompany chorea, but it requires to be given in increasing doses as the 
stomach becomes more and more accustomed to it. Two- or three-minim 
doses may be given three times a day at first, and increased at the rate of 
an extra minim every week till six or seven minims are given. It is better 
not to continue the administration for too long together, as a temporary 
darkening of the skin is apt to take place. The administration may be 
omitted for a week or two, and then recommenced. In the latter stages iron 
may be useful, given in combination with arsenic. Great care should be 
taken to regulate the bowels ; constipation is the rule, and this may be 
overcome by small pilules of extract of aloes or some elixir of cascara 
sagrada. 

In chronic cases a change of scene, such as residence at the seaside, is 
often suggested by the friends; but in our experience this change often 
makes the movements worse and prolongs the attack, in consequence of 
the excitement attending the change and the patient attempting to do more 
than her strength permits. A change to the seaside should be deferred till 
the movements have nearly ceased and can be controlled entirely by the will. 
The same may be said of gymnastic exercises and rhythmical movements ; 
they are of the greatest use when the movements tend to become habitual, 
while the health of the patient is good ; they are certainly not desirable in the 
earlier stages. Massage has been employed with good result by Goodhart 
and Phillips, and in some of our own and our colleagues' cases the result 
has been satisfactory. All through the course of chorea moral treatment is 
of the greatest importance. Chorea in many cases is closely allied to hysteria, 
and a firm but kindly demeanour towards the patient is called for ; and she 
should be encouraged to control the movements as much as possible by an 
effort of will. In all severe cases a nurse should be provided, as the patient's 
mother is often the last person who should have charge of her. 

In all stages of the attack a nourishing, easily digested diet is necessary ; 
in severe cases it is necessary to feed the patient ; in such patients fluid food 
only can be administered. 

Epilepsy 

Convulsive seizures of various degrees of severity are common during 
childhood and youth, and when they are idiopathic — that is, without assign- 



Epilepsy 527 

able cause, no cerebral or other lesion being discoverable — the term 
'epileptic' is applied to them. It is difficult to say in what proportion of 
cases children who suffer from convulsions during infancy become confirmed 
epileptics ; certainly the majority of those who suffer from infantile con- 
vulsions lose this tendency to convulsive seizures as they grow older. In 
only about \2\ per cent, of cases of chronic epilepsy is there a history of 
the fits commencing during the first three years of life, and in a smaller 
percentage (5^) during the first year. (Cowers.) According to statistics 
collected by Gowers, in one-fourth of the total number the attacks begin 
before the age of ten years, and nearly one-half between the ages of ten and 
twenty years. These statistics show that there is always the possibility that 
children or infants who suffer from reflex convulsions may become epileptics ; 
yet there is a strong probability, if the child does not suffer from any cerebral 
defect, or has no hereditary tendency in the direction of epilepsy, that he will 
not grow up an epileptic. Hereditary influences certainly predispose ; a 
family history of epilepsy or insanity is obtained in about one-third of the 
cases of epilepsy, in others it may be found that they come of neurotic 
families in which members have suffered from chorea or hysteria. 

Of the exciting causes there is little to be said. The first fit may be 
described by the friends as being due to a ' sunstroke, 5 or a ' blow on the 
head,' or a ' fright ; ' but it is unsafe to place much reliance on such state- 
ments, as they may be merely coincidences, and certainly are not sufficient 
in themselves to produce epilepsy. In the large majority of cases, it must be 
confessed, no immediate cause can be discovered. Epilepsy sometimes 
commences after scarlet fever and other zymotic diseases, but beyond the 
fact that these fevers leave a certain amount of weakness behind, and so may 
predispose, there is nothing to suggest that they act as effectual causes. The 
approach of puberty is a time when the nervous system is in an excitable 
state, especially in girls, and epileptic fits are very apt to commence at this 
period, notably in cases where menstruation does not commence at the 
usual period, but is delayed by any cause. Constipated bowels and a slug- 
gish condition of liver certainly act as predisposing causes. 

Symptojns. — Two forms of attack are usually described : the minor form, 
or petit i?ial, and the major form, ox grand mat ; but these two forms insen- 
sibly pass into one another, and there is no marked line of demarcation 
between them. 

The precursory symptoms differ very much : frequently the first fits and 
the succeeding fits come in the midst of perfect health, and neither the 
patient nor his friends are aware that a fit is imminent. On the other hand, 
the child may be unusually irritable, easily put out, and nothing pleases it ; 
it may be feverish, dull, and stupid. In some cases the fit is preceded by 
some warning or aura, by which the patient becomes aware, by past 
experience, that an attack is at hand. These aura? are more common in 
adults than in children, or at any rate adults are better able to describe their 
feelings and have a larger experience of fits to fall back upon. The aurse are 
very diverse in character : they may be sensations referred to an arm or leg, 
or to the throat ; there may be headache, vertigo, or faintness. 

Petit mal. — These minor attacks are very slight in character and are 
often not admitted to be epileptic by the friends, who usually connect ' fits ' 



528 Diseases of the Nervous System 

with the more severe and decided form of seizure. They are often spoken 
of as l faints ' or ' attacks.' There may be no real convulsion or tonic spasm ; 
the child may stumble when walking from a momentary impairment of 
consciousness ; a peculiar look crosses its face, and for a moment it is dazed 
and forgets what has happened. Sometimes the face becomes pallid for 
a moment, and there is a slight convulsive spasrn of the facial or other 
muscles. The urine is rarely passed in these seizures, nor is there any cry. 
Sometimes the attack is succeeded by drowsiness or stupor. In older 
children the behaviour may be very peculiar ; after one of these minor 
seizures a mild mania may seize the patient, he becomes mischievous or 
strikes other children without provocation, or behaves in an hysterical 
manner. 

Grand mat. — The seizure may begin with a sharp cry or scream, as of 
sudden fright ; in many cases this cry is absent, the patient falling precipi- 
tately onto the ground in an unconscious state. The face is pallid and 
tonic spasms of the muscles begin. Sometimes these are one-sided in dis- 
tribution : the muscles of one side of the face, neck, arm, and leg of the same 
side are thrown into contraction, the head is usually rotated to the affected 
side. In other cases the spasms are general. The legs are usually extended 
and stiff, the elbows partially bent, the wrists flexed, and the fingers in a 
position of interosseous spasm. (Gowers.) The respiratory muscles join 
in the general tonic spasm, and, as the inspiratory muscles are more powerful 
than the expiratory, the breath is drawn in and held, so that the face becomes 
congested and the lips blue. There is usually spasmodic contraction of the 
muscles of the jaw, so that the tongue is bitten and held between the teeth ; 
frothy, perhaps blood-stained, saliva runs from the patient's mouth. Death 
may take place from asphyxia during this stage. Usually, however, after 
the stage of tonic spasm has lasted from a few to thirty seconds, the con- 
tinued spasm of the muscles relaxes, and clonic or intermittent short con- 
tractions succeed. The muscles of the face twitch, so that the patient 
appears as if he were making grimaces ; the limbs ' work,' alternately flexing 
and extending — sometimes so violently that the head and legs are banged 
about and become bruised and injured. In other cases the clonic spasm is 
not so vigorous, there being only short, sharp, muscular contractions. The 
urine and sometimes the faeces are passed. The period of the clonic spasm 
is variable ; it may last many minutes, or even hours ; the patient gradually 
recovers consciousness, and lias no recollection of what has passed. He 
probably is dazed and sleepy, goes off to sleep, and wakes up tired and sore. 
The fits vary much in intensity : often the stage of tonic spasm is short and 
not well marked, and the whole duration of the fit is not more than half a 
minute. In some cases, especially after severe attacks, a temporary para- 
lysis, mostly hemiplegic, is left. We are inclined to attribute this to a 
meningeal haemorrhage which has taken place during the respiratory spasm. 
Hysteroid Pits. — Some minor attacks closely resemble hysteria in that 
the spasmodic movements are of a purposeful character, as if directed by 
the will, and, moreover, the child appears to be conscious or semi-conscious 
during the fit. This form of seizure is common both in boys and girls. 
The phenomena which take place are exceedingly various ; the child may 
commence by barking like a dog, or mewing like a cat, or may attempt to 



Epilepsy 529 

bite its attendants ; the head may be banged about and the legs and arms 
thrown wildly about, as if the child were directing the movements. The 
patient may stiffen out and arch his back as in opisthotonos. Sometimes 
the actions are still more co-ordinated. Thus in a girl of seven years, in 
hospital, when an attack came on she would jump up in bed, turn round 
once or twice, sit down again and arrange the bedclothes, smoothing them 
carefully down, and yet be unconscious during the fit, and have no remem- 
brance of it afterwards. A sharp word or the prick of a pin will often 
arrest these fits. That some of these cases are closely related to epilepsy is 
shown by the fact that they may alternate with true epileptic fits or they may 
supervene at puberty in children who have suffered from chronic epilepsy. 

Post-hemipleglc Epilepsy. — Children who suffer from hemiplegia which 
dates from birth or within a year or two of birth are very apt to suffer from 
epileptiform attacks. Convulsions are also very apt to attend the onset of the 
hemiplegia : the child may continue to have fits, and be subject to them for 
the rest of its life. In other cases a period of months or years may elapse 
between the onset of the hemiplegia and the commencement of the epileptic 
fits. It is often about puberty that they recur. As a rule, the convulsions 
affect the paralysed side only, but in severe cases the convulsions may be 
general. An aura or warning of the approaching fit is more common in 
post-hemiplegic epilepsy than in idiopathic epilepsy. In these cases it is 
common for mental backwardness to exist (see case, p. 556). 

Course. — As already stated, the epileptic fits may date from infancy, the 
child having suffered in the early months or years of its life from convul- 
sions, and these have been succeeded by chronic epilepsy. More often the 
child has been free from convulsive seizures during infancy and early child- 
hood, and it is only during the second dentition or as puberty is approached 
that it has begun to suffer from fits. The health prior to the commence- 
ment of the fits may have been excellent, there may be no history of epilepsy 
in the family, and it may be quite impossible to explain the onset of epileptic 
fits. At first the friends are loth to believe the fits to be epileptic, and attri- 
bute them to rapid growth, dentition, weakness, or some injury. In other 
cases the health may have been indifferent or the temperament peculiar, 
the child having been of a strange disposition,' nervous, easily frightened, 
morose, or backward in mental development, or may have shown signs of 
idiocy, and then, as puberty approaches, commences with epileptic fits. The 
health of the child after the commencement of the fits varies according to 
their frequency and severity. In the milder forms the children may enjoy 
the best of health, may be merry, romping children, able to take their part 
in rough school games, and be of average, or more than ordinary, quickness 
and intelligence. In other cases, especially when the fits occur frequently, 
the health suffers, the patient becomes sallow and anaemic, his digestion 
and appetite are poor, and the liver and bowels sluggish. The memory is 
apt to fail more or less, and in the worst cases a condition allied to dementia 
may supervene. The intervals between the fits differ considerably, not only 
in different patients, but in the same individual ; sometimes many months or 
even years will pass without a fit, at other times the fits follow one another 
at intervals of a few minutes, so that the patient is no sooner out of one fit 
than he is into another. To this latter condition the term ' status epilepticus ' 

M M 



530 Diseases of the Nervous System 

has been applied. In the petit mat the fits usually occur oftener than in 
the more severe attacks. Fits may occur at any time in the twenty-four 
hours, at night or by day, but there seems to be a special tendency for them 
to recur in the early morning when the patient is getting up. 

Prognosis. — The prognosis is bad in those who have suffered from fits 
from infancy, and who are mentally deficient, or in whom some mental 
change has taken place. The chance of the entire cessation of the fits is a 
poor one in those who have fits frequently. The less frequent the fits, the 
greater is the probability that they may cease altogether. Even in those who 
have only suffered from fits at long intervals a cautious prognosis must be 
given, as those who have so suffered are never safe, and a recurrence may 
at any time take place. The danger to life is least in the minor attacks, but 
as time goes on the major attacks may supervene. There is always the 
possibility that the fits may cease when the epoch of puberty is passed, and 
in the case of girls when menstruation is thoroughly established. It must 
always be borne in mind that epileptics may at any time meet with a sudden 
death from injuries received during a fit : they may fall into the fire, or into 
water, or they may be suffocated in bed at night. Less often death takes 
place in the fit from asphyxia, due to prolonged spasm of the glottis and 
respiratory muscles. 

Diagnosis. — In some cases of petit mat the attack maybe so slight that a 
doubt may exist whether the fits are really epileptic or not ; but all recurring 
' faints ' or attacks of giddiness must be looked upon with great suspicion, 
and if there is a loss of consciousness, however short, they are almost 
certainly epileptic. Difficulty may often arise in distinguishing hysterical 
attacks from true epilepsy, especially the attacks described as hysteroid. It 
may be simply a matter of opinion whether some of these attacks are best 
classed with epilepsy or hysteria ; in any given case careful inquiry must be 
made for typical epileptic fits, which sometimes occur immediately before 
the hysteroid fits. The diagnosis is usually easy between typical epileptic 
and typical hysterical fits ; it is often very uncertain in atypical ones. Loss 
of consciousness, biting the tongue, or tonic followed by clonic spasms, if 
present, are decisive in favour of epilepsy. There may often be considerable 
difficulty in distinguishing between reflex convulsions and epileptic fits. 
Under three years of age, if there are the signs of rickets, the probabilities 
are strongly in favour of their being reflex. After this age reflex con- 
vulsions may occur at the commencement of some zymotic disease, or 
possibly as the result of cutting the permanent teeth, or from worms ; but the 
chances are immensely in favour of epilepsy if they are on the type of those 
in idiopathic epilepsy ; in all cases where the attacks are epileptiform in 
character, in which there is loss of consciousness, spasm followed by stupor, 
even though the child is cutting one of the permanent teeth or had worms, 
we should be inclined to believe they are really epileptic. Parents naturally 
like to believe that the fits are due to dentition, to rapid growth, to a dis- 
ordered liver or stomach, especially in those cases where there are no here- 
ditary tendencies present, but we cannot accept these as anything more than 
exciting causes, and in all such cases there is only too much reason to fear 
that there may be a recurrence of the attacks. Convulsions may occur as the 
result of brain disease, recent as well as old. A tumour or syphilis may be 



Epilepsy 531 

present in this case ; there may be some marked aura, especially visual or 
auditor)' ; the convulsions will be mostly one-sided ; moreover, there is 
headache, giddiness, vomiting, paralysis, and optic neuritis. 

Treatme7it.—A child subject to epileptic fits should be placed under the 
most favourable conditions possible, and should be most carefully guarded 
from excitement, over-fatigue, and over-feeding. A healthy country life, with 
plenty of outdoor exercise and sufficient employment for the mind, must be 
enjoined. A moderate amount of brain work may be allowed, but no forcing 
of any kind should be permitted. It is well to allow no work and not much 
exercise before breakfast, as at this time there appears to be an especial 
liability to fits. The diet should be simple and unstimulating ; in some cases 
coming under our notice children have done better when butchers meat 
has been excluded from their diet or only taken sparingly. How useful a 
regular life is, is seen by the improvement which nearly always takes 
place on the child's admission to hospital. It is needless to say that all 
children subject to fits should be carefully watched : a public or large 
school is certainly not the place for them, as they require more individual 
attention than is possible under such conditions. There is always the 
possibility that they may fall into the fire, or into water, or be suffocated 
in bed by a fit occurring during the night. The state of the bowels should 
be most carefully attended to, as there can be no question that constipated 
bowels predispose to the attacks. Effervescing citrate of potash, magnesia, 
or cascara, with occasional small doses of calomel, are useful. Of all medicines 
which check the tendency to fits the bromides take first place. Bromide of 
potassium or sodium maybe given in doses of 10 to 40 grains a day, according 
to age and to the frequency of the fits. The saline taste is readily covered 
by well diluting with water, and adding syrup of orange peel, aromatic sp. of 
ammonia, or liq. ext. of liquorice. (F. 85, 86, 87.) 

Sometimes a laxative may be combined with the bromide to counteract 
its constipating action : sulphate of magnesia, tincture or infusion of rhu- 
barb, or ' cascara cordial ' or ' elixir,' may be used, but, as a laxative can be 
given as required, it is usually unnecessary to combine one with the bromide. 
The bromide should be administered for a month at least after the fits, and 
then may be reduced in quantity ; but it will be well to continue the use of 
bromide in gradually smaller doses for six months at least after the last fit : 
it may be combined with digitalis or tonics, such as cinchona, iron, or mix 
vomica. 

Large doses of bromide give rise to a lethargic heavy condition in the 
patient ; there may be slow drawling speech, and a slow circulation. Acne 
is apt to make its appearance after a few doses of bromide in some 
patients. 

There is no other drug that at all approaches bromide in value for epilepsy. 
Nitrite of sodium, belladonna, zinc oxide or lactate (| to 5 grs.), borax (5 to 
10 grs.), nitro-glycerine (oi)T5- to Tinr of a g ranl )> and strychnine have all been 
used with more or less advantage when bromide fails. 

The question of surgical interference must depend upon the diagnosis ; 
in idiopathic epilepsy trephining or ligature of the carotids is hardly justi- 
fiable. If there is reason to believe that a tumour in the cortex exists, an 
operation may be considered (see p. 499). 

M M 2 



532 Diseases of the Nervous System 

Infantile Convulsions. Eclampsia. — Infancy predisposes to those 
irregular nerve discharges which go by the name of 'convulsions' or 
eclampsia. The undeveloped state of the cortical centres during infancy, 
and the consequent absence or imperfection of the controlling or inhibitory 
influences exercised by these centres in later life, allow the 'lower grade 7 
centres to discharge their stored nervous force, when stimulated, in a way 
which does not occur in later years. The reflex actions exhibited by the 
brainless frog are more easily provoked and more vigorous than the reflex 
actions exhibited by a frog with the brain intact ; the higher centres appear- 
ing to exercise a controlling influence. 

While infancy is the time of life in which convulsions are most easily 
provoked, yet healthy infants do not become convulsed unless the stimulus 
is strong ; it is the delicate ones who are most likely to suffer, and especially 
those who have inherited neurotic tendencies. That hereditary influences 
play an important part there can hardly be a doubt, the infants of those who 
have suffered from epilepsy or who are of a highly nervous disposition 
certainly more often suffer from reflex convulsions than do the children of 
strong, healthy parents. The commonest predisposing cause, however, is 
rickets, though in what way it acts is uncertain ; yet it is certain that all the 
tissues in rickets are badly nourished and built up, and the nervous system 
is no exception to this : the nerve centres appear to be in a condition of 
unstable equilibrium, and are apt to discharge their nervous force in a pur- 
poseless and irregular manner. Very probably some toxine is formed in the 
alimentary canal, which produces a sensitive state of the nervous centres. 
In the large majority of children who suffer from convulsions between the 
ages of six months and three years the signs of rickets are present. An 
anaemic condition, great exhaustion from any cause, as well as hereditary 
tendencies, predispose to convulsions during the whole period of childhood, 
but more especially during the first few months of life. 

The exciting causes of convulsions are mostly reflex : the irritation takes 
place at some distant part, the stimulus passes up to the nerve centre along 
some afferent nerve, giving rise to a discharge from a nerve centre or 
centres, the impulse travelling along the efferent nerves to the muscles. 

Reflex convulsions may be said to be disorderly physiological reflex acts. 
In a normal reflex act the nervous mechanism is properly controlled and a 
useful movement takes place : in a convulsion there is an irregular and 
wasteful discharge of nerve force which fulfils no useful end. An infant's 
movements consist almost entirely of reflex acts of the simplest character, 
the nerve centres in action being of the ' lower grade ' group, situated in the 
spinal cord, medulla, and pons : such are the acts of swallowing, sucking, 
crying, breathing ; in each case there is some form of irritation, or a stimulus 
acting on the nerve centre and transmitted to it by an afferent nerve, and an 
impulse is sent along an efferent nerve to a muscle or group of muscles, and 
a definite, perhaps complex, act is performed. In morbid states of the nerve 
centres an afferent impulse calls forth a series of irregular and muscular move- 
ments, mostly in the form of clonic spasms, which may be limited to one 
group of muscles, or may implicate almost all the voluntary muscles in the 
body. Thus the presence of undigested curd in the stomach or bowels gives 
rise to acute pain or griping, and acts as a stimulus over a wide area, and 



Infantile Convulsions 533 

some distant nerve centre, or perhaps many nerve centres, are thrown into 
activity. As a consequence of this the facial muscles may twitch, the legs 
be drawn up, the eyes roll about, the fingers be clenched ; there may be 
spasm of the respiratory muscles, and all the muscles of the extremities may 
be thrown into clonic spasm ; or the infant suffers from whooping cough, and 
the spasm of the glottis passes into a general convulsion. Possibly the res- 
piratory muscles only may be involved, and spasm of the glottis and of the 
respiratory muscles may result. Dyspepsia or the presence of indigestible 
food is a fertile source of infantile convulsions in the newly born ; newly born 
infants when fed on artificial food frequently suffer from convulsions, which 
disappear at once when a wet-nurse is obtained. In making post-mortems 
on infants and young children who have died in convulsions it is no uncommon 
thing to find an overloaded stomach, and possibly pieces of meat and other 
indigestible food in the stomach. 

Dentition is another cause : the pressure of the advancing tooth upon the 
gum, or the tension of the tooth in its socket, may, through the branches of 
the fifth nerve, produce general convulsions. Bronchitis or pneumonia may 
be the exciting cause, though the latter sometimes produces convulsions in 
consequence of the high fever that is present. 

The exciting cause of the convulsions may act directly on the centres 
themselves. Thus the onset of meningitis or any part of its course may be 
marked by convulsions ; an infant has a series of convulsions which are 
perhaps more or less one-sided, and when they cease it is noticed to be 
hemiplegic, due, as we have already explained, to cerebral haemorrhage (see 
Cerebral Haemorrhage). The acute stage of infantile paralysis may be 
attended with convulsions. Convulsions may be caused by chronic brain 
disease. A poisoned condition of blood may be the exciting cause ; thus a 
temperature of 104 or 105 is exceedingly likely to-be accompanied by con- 
vulsions, the convulsions ceasing when the temperature falls, and being 
perhaps repeated when it rises again. Heat-convulsions are exceedingly apt 
to be fatal. A hypervenous condition of blood excites convulsions, as seen in 
infants born in a condition of asphyxia. The onset of some zymotic disease, 
as scarlet fever, measles, or influenza, is sometimes marked by convulsions. 

Symptoms. — The convulsive attacks vary greatly in their severity, and in 
the extent of the muscles involved. They may simply be slight jerky move- 
ments of the head and neck, or a limb, or there may be slight twitchings of 
the muscles of the mouth or eyelids. The fingers may jerk and the thumbs 
turn in, the toes become flexed, movements to which the name of carpo-pedal 
contractions has been applied. Such slight convulsions are often spoken of 
by nurses and parents as ' inward fits ; ' they are most common in young 
babies with dyspepsia, or those who are suffering from distended bowels. 

A typical convulsion closely resembles an epileptic fit, but the stage of 
tonic spasm is usually shorter, while the clonic spasms or muscular twitch- 
ings are more prolonged and vigorous. The commencement of a fit is 
frequently marked by a spasm of the glottis, so that the nurse thinks for the 
moment the infant is choking ; at other times the rolling upwards of the 
eyeballs and twitchings of the facial muscles first call attention to the child. 
The face becomes pallid, the eyes are turned up so as to show ' the whites,' 
the limbs are extended and stiffened, the hands are clenched, the neck and 



534 Diseases of the Nervous System 

back are arched, the jaw closes spasmodically ; in a few moments the lips 
and face become of a bluish tinge from the respiratory spasm ; the tonic 
spasm quickly passes into clonic, the hands, feet, and face ' work ' for a few 
seconds or more, and the child becomes quiescent and the fit is over. The 
child becomes unconscious during the fit, and may remain dazed for a few 
minutes to half an hour after. 

The fits may be severe, much of the type of a major epileptic fit, the 
tongue being held tightly between the gums or injured by the teeth, the child 
frothing at the mouth and becoming cyanosed, and remaining comatose or 
drowsy for some time. On the other hand, the convulsions may be partial 
only : one side may be affected, the leg, arm, and side of the face twitching, 
or the laryngeal muscles or respiratory muscles alone may suffer. The fre- 
quency with which fits occur differs very much : a child may have a single 
one, and it may never be repeated ; or they may recur daily, or there may 
be a constant succession of fits for twenty-four or forty-eight hours, the child 
never becoming conscious. Some of the most severe convulsions we have 
ever witnessed have been in connection with whooping cough. The child 
begins to cough and forthwith a general spasm of the respiratory muscles 
takes place, with spasm perhaps of the muscles of the limbs. The child 
becomes dusky or pallid, and appears to be dead. Perhaps by the aid of 
artificial respiration it comes round, but such attacks are, we need not say, 
exceedingly fatal. 

Death may take place in the fit from spasm of the glottis. In other 
cases death seems to be caused in some way through the nervous system, as 
after death no evidence of asphyxia can be found. Convulsions in older 
children are indistinguishable from epileptic fits, and doubtless many of such 
cases for which no cause is found are really epileptic, or at any rate showing 
a tendency in that direction. 

Convulsions may be associated with idiocy or some mental defect, and 
it is not always easy to say to what extent the convulsions depend upon the 
presence of some cerebral lesion or malformation, or whether the mental 
defect is produced by the frequently recurring fits. It is not uncommon to 
see children of a few months to a year old who are frequently convulsed, 
and who are evidently idiots, not able to sit up or hold anything in their 
hands, and not recognising their friends. In these cases the prognosis, as 
far as the mental development is concerned, is grave, though the fits often 
become less frequent or cease as the infant develops. 

Pi'ognosis. — This must always be uncertain, and naturally depends upon the 
exciting causes. The first fit may prove fatal through spasm of the glottis ; 
on the other hand, it is common to get a history of children who as infants 
were constantly convulsed and yet have grown into comparatively strong- 
children. Naturally much must depend upon what the exciting cause of the 
fit is : if it suggest commencing meningitis the prognosis is necessarily bad ; 
if there is hyperpyrexia and commencing pneumonia it is very grave. Con- 
vulsions following on some exhausting disease, as diarrhoea, are mostly fatal. 
Convulsions associated with laryngismus are always serious, and the prognosis 
must be very guarded. In those cases where the fits in young infants are 
frequently repeated, it must be borne in mind that they may prove to be 
epileptic or associated with mental deficiency, and a guarded prognosis must 



Infantile Convulsions 535 

be given. If there is reason to believe that the convulsions are due to 
dyspepsia or are symptomatic of rickets, the prognosis as far as the cerebral 
development of the child is concerned is good, but there is always the risk 
of its dying in a fit. 

Diagnosis. — The exciting cause of the convulsions may be difficult or 
impossible to determine. Convulsions in infants shortly after birth may be 
due to a hypervenous state of the blood resulting from congenital heart 
disease or atelectasis, or to a meningeal haemorrhage, which has taken 
place during birth. If these can be excluded there is a strong probability that 
the fits are due to some digestive disturbance, especially if the infant is being 
artificially nursed. In infants over six months of age, with the symptoms of 
rickets, the fits are in all probability reflex and due to some alimentary 
troubles such as flatulence, or griping in order to expel undigested curd ; but 
the possibility of their being due to commencing meningitis or to the presence 
of tubercles in the brain must always be borne in mind, even in the case of fat, 
healthy-looking infants. Vomiting, irregularity or hesitation of the pulse- 
beat, or an unnatural softness of the abdomen would suggest meningitis. 
The possibility of the convulsions in infants being followed by a hemiplegia 
or a paralysis of one or more limbs must not be forgotten. In convulsions 
in young children the chest should be carefully examined and the tempera- 
ture taken, and the skin inspected to ascertain the presence or absence of a 
rash. In frequently recurring fits there is a possibility that the child may 
grow up mentally deficient, and a careful inquiry should be made as to the 
child's intelligence. 

The fact that infants often suffer from one-sided convulsions, or that the 
convulsion begins on one side, must not be taken to indicate that there is brain 
disease of the opposite side, inasmuch as reflex convulsions due to intestinal 
irritation may be one-sided in the first instance. 

Morbid Anatomy. — Convulsions per se leave no trace in the dead body, 
though usually there are the signs of death from asphyxia, the latter being 
most marked in those dying suddenly in strong health. The veins on the 
surface of the brain are full of dark blood, there are punctiform or larger 
haemorrhages, and the brain may be unusually full of blood and wet from 
excess of cerebro-spinal fluid on the surface and in the lateral ventricles, but 
these conditions are due to death taking place through stasis of blood in the 
lungs and a consequent engorgement of the general venous system. The 
post-mortem examination of the state of the cerebral vessels gives us no clue to 
their condition, whether of engorgement or anaemia, during the fit itself, except 
such as are produced by venous obstruction. In many cases the autopsy 
throws no light on either : the cause of the fit or the conditions which 
accompanied the fit. In others the appearances of commencing bronchitis 
or pneumonia or acute intestinal catarrh may be found. Difficulties are, 
however, likely to be met with at the post-mortem in distinguishing between 
early pneumonia and the sodden and cedematous lung often present which 
is due to the manner of death — namely, asphyxia from obstruction to the 
entrance of air into the larynx. 

In making an examination for medico-legal inquiries as to the cause of 
death, whether from a convulsion or from some other cause, great caution 
must be exercised in coming to a conclusion, especially in infants. An infant 



536 Diseases of the Nervous System 

may have been ' overlain,' i.e. suffocated beneath the bedclothes in conse- 
quence of the mother going to sleep with the infant at the breast, the mother 
perhaps alleging that the infant had died in a fit. In both cases the after- 
death appearances may perhaps be much alike — namely, those of death from 
asphyxia. In many cases, however, a distinction may be made between a 
rapidly produced asphyxia as in death from a fit, and a more slowly produced 
asphyxia, as in slow suffocation beneath the bedclothes : in the former the 
lungs are simply gorged with dark fluid blood, in the latter case the lungs 
are sodden and cedematous, containing a large amount of frothy fluid. In 
any case where the tongue is held between the teeth and has been injured, 
and there are signs of rickets, the lungs gorged with dark fluid, and the veins 
on the surface of the brain overfull, there is a strong probability that the 
child has died in a fit. It must not, however, be too hastily assumed that 
a convulsion has not been the cause of death, because the typical signs of 
asphyxia are not present ; death appears to take place in some cases pro- 
bably through the nervous system, before asphyxia takes place. 

Treatment. — The treatment of convulsions must necessarily be chiefly 
directed to removing the cause. During the convulsion itself, if there is a 
high temperature (io4°-io6°), no time should be lost in placing the infant 
or child in a tepid bath and pouring cold water over the child and into the 
bath in order to lower' the temperature, which is probably exciting the con- 
vulsions, and it may be also necessary to give antifebrin or quinine. In reflex 
convulsions in a robust child, especially if there is colic or abdominal dis- 
turbance, a warm bath, or a mustard bath so as to redden the skin, is likely 
to prove of service, or the child's socks may be wrung out of mustard and 
water and placed on the feet, or hot flannels may be placed on the abdomen. 
If there is reason to suppose the convulsions are due to cerebral disease, 
or the convulsions come on at the end of an exhausting illness, the warm 
bath is not likely to be of any service and may be injurious. If the child 
has taken any indigestible food, which is lying in the stomach or in the 
bowels, an emetic or one or two grains of calomel should be administered 
according to the effect desired. If the gums are swollen and tender, an 
incision, or simply scarifying them, will often do good. If there is otitis, it 
may be well to puncture the membrane. 

The inhalation of a few drops of chloroform or nitrite of amyl will 
usually check the violence of the convulsive spasms, and should certainly 
be tried if the convulsions last any time or are violent. Of medicines 
which diminish the irritability of the nervous centres, the bromides, chloral, 
and belladonna hold the first place. Bromide of potassium or sodium must 
be given freely if the convulsions recur time after time. If the child can 
swallow, 3 to 5 grains may be given to an infant of six months to a year old, 
and repeated every hour or two for several doses, according as the convul- 
sions are present or not ; smaller doses, less often repeated, should be given 
if improvement takes place. Xo harm is likely to ensue by pushing the 
bromide. The bromide may be given by the rectum if necessary. Chloral 
is in some cases more useful than bromide, but it must be used more 
sparingly ; a two- or three-grain dose may be given to an infant under a year, 
and repeated in an hour if the convulsions are still present, but its soporific 
effect must be watched. Chloral, we are inclined to think, is more useful 



Tetany 537 

than bromide in convulsions due to colic or whooping cough. Bromide, 
choral, and cannabis indica are often given in combination with advantage 
in convulsions. (F. 88, 89, 90.) Cold to the head in the form of ice or wet 
cloths should be used if meningitis is suspected, and the infant should 
be carefully protected from all excitement. 

Convulsions in infants a few weeks old, who are artificially fed, are due 
in the large majority of cases to dyspepsia, and no time should be lost in 
procuring a wet-nurse, or at any rate in giving the infant the most suitable 
food that can be procured. The bromides will have but little effect in stop- 
ping the convulsions as long as acute dyspepsia or colic is present. 

Tetany 

The term ' tetany ' is applied to a form of tonic spasm mostly affecting 
the extremities, which, like spasm of the glottis, consists in a reflex con- 
traction of a group of muscles, the result of irritation in some distant 
part. Tetany may affect both children and adults, though it is commoner 




Tetany affecting limbs, also muscles of neck. 



before the age of three years than after this period. It is frequently asso- 
ciated with rickets, in this respect resembling convulsions and laryngeal 
spasm ; it frequently occurs in connection with laryngismus. It rarely 
makes its appearance in healthy children, but in those who have suffered 
from some exhausting disease, especially some affection of the alimentary 
canal, as diarrhoea or acute enteritis ; prolapse of the rectum may be an 
exciting cause. Difficult dentition appears to be an occasional cause. One 
of the most severe cases we have seen was associated with a fatal attack of 
acute enteritis. It has been observed in rare instances as an early symptom 
in pneumonia and other diseases, in this respect resembling convulsions, 
and tonic contraction of the muscles at the back of the neck. It has some- 
times prevailed epidemically among school-girls, but in such cases the 
muscular contractions were no doubt due to hysteria. 

Symptoms and Course. — The attacks consist in spasms of the muscles of 
the extremities, more especially of the forearms and feet. There is no loss 
of consciousness, and usually no spasm of the facial muscles, though there 
is mostly an expression of pain on the face when the cramps come on. In 
the severer cases the arm is adducted at the shoulder and fixed to the side, 



53& Diseases of the Nervous System 

the elbow is flexed at right angles, the forearm pronated, the wrist flexed, the 
thumb turned in, while the fingers are in the position of interosseous spasm, 
forming what is known as the 'accoucheurs hand;' in other cases the 
fingers are spread out (see fig. 114). 

In the lower extremities the foot is in the position of talipes equinus or 
equino- varus, the plantar surfaces being hollowed out and the toes bent. 
The knees may be semi-flexed and the thighs adducted. The muscles of 
the calf are hard and rigid, feeling as if gathered up into a ball. There is 
usually oedema of the dorsum of the feet and hands, from interference with 
the venous circulation. 

The contractions are evidently painful ; the infants scream when they 
are handled or interfered with ; the spasms may intermit, but usually last a 
considerable time. In rare cases, notably those recorded by Cheadle, the 

muscles of the face are thrown 
into spasm ; in other cases the 
muscles of the jaw, abdomen, 
neck, and back have been 
affected (see fig. 113). More 
commonly the spasm is con- 
fined to the hands and feet, 
or the hands only may be 
affected. The spasm lasts from 
a few minutes to many hours 
or even days, then disappear- 
ing and perhaps appearing 
again. Most of the muscles 
of the body are in a condition 
of irritability, especially those 
of the face. This is evidenced 
by the readiness with which 
they contract when the facial 
nerve is irritated. If the finger 
be passed smartly over the 
angle of the mouth, a sharp 
contraction of the levator fol- 
lows ; or the finger is brushed 
across the outer side of the 
orbit, and a contraction of the 
orbicularis ensues. This 'facial 
phenomenon,' however, is not 
peculiar in tetany. 1 The same irritable condition of muscles can sometimes 
be demonstrated by compression of the large nerve trunks of the arm, which 
may give rise to muscular spasm in the hands and fingers. This is sometimes 
referred to as ' Trousseau's phenomenon.' 

Tetany never threatens life per se, as it only affects the muscles of external 
relation, though the child may die from the effects of the gastro-enteritis, 
of which the muscle cramps are only symptoms. The only case which 

1 J. Loos, M.D., Wiener klin. Wockenschr.No, 49, 1891 ; ' Laryngismus, ' Dr. W. 
Gay, Brain, January 1890. 




Fig. 



C4. — Tetany of the hands and feet (from a 
photograph by Dr. L. W. Crowe). 



Tetany — Nystagm us 539 

terminated fatally, which we have seen, was the case, referred to above, of 
a boy aged six years, who died in a few days from the effects of a gastro- 
enteritis ; the principal symptoms were constant vomiting, cramps in the 
stomach, and tetany of both upper and lower extremities. The post-mortem 
showed the brain and cord to be normal to the naked eye ; the mucous 
membranes of the stomach and intestines were injected, and evidently in a 
state of acute catarrh. In another case, somewhat similar, Hadden could 
find no changes in the cord. 

Tetany is apt to return from time to time after a considerable interval ; 
this may be noticed in cases received into hospital : these mostly get well 
quickly and go home, but in another week or two are as bad as ever. 

Diagnosis. — Tetany may be mistaken for cerebro-spinal meningitis, but it 
can only thus be mistaken when the constitutional symptoms accompanying 
the tetany are severe. In tetany there is an absence of cerebral symptoms 
as well as of vomiting and fever. In tetanus the spasm of the masseters is 
an early symptom ; it is absent in tetany, or comes on late in the attack. 
The position of the fingers is different in the two diseases. In girls or older 
boys hysterical contraction might stimulate tetany, but the former usually 
affects one limb, or an arm and a leg only, while the latter is always bilateral. 

Treatme?it. — The treatment must be directed in the first place to the 
exciting cause. A dose of calomel or grey powder should be given if there 
is any gastro-intestinal disturbance or undigested food lodging in the 
intestinal tract, and the greatest care taken to give only the blandest food. 
Warm baths may be given to relieve the spasm, and hot laudanum fomen- 
tations applied to the hands and feet. Bromide of potassium is likely to 
relieve the symptoms if given in full doses. Chloral, belladonna, digitalis, 
and Calabar bean have all been used with benefit. Cheadle found the ■£% 
to \ dose of Calabar bean of use in one case. 

nystagmus. — Nystagmus is common during both infancy and childhood 
and accompanies very different conditions. It usually consists in short 
rapid oscillations of the eyeballs in a lateral direction, the head sometimes 
moving also. In some cases the ocular movements are vertical instead of 
lateral. It may be present in congenital cataract, tumours of the brain, 
hydrocephalus and hereditary ataxia ; but it is also present in children who 
are not suffering from any organic disease. It may be present in some forms 
of clonic spasm of the neck. 

Head-nodding: and Head-shaking-, going on constantly as they some- 
times do in infants and young children, are the result of a chronic reflex 
spasm of the sterno-mastoids, either both acting together and making a 
nodding movement, as in expressing assent, or acting alternately and shaking 
the head as if expressing dissent. The movements may be constant or 
intermittent, perhaps ten or twelve times a minute. Nystagmus may be 
present. These curious spasmodic affections appear to be allied to laryn- 
gismus. Dr. Gee records a case whose brother died of laryngismus, and in 
one case of ' head-nodding ' mentioned by A. Baginsky, the child suffered 
later from convulsions and laryngismus. Head-shaking in older children 
Dr. Gee connects with epilepsy. The prognosis is good ; like laryngismus, 
these affections appear to be due to some reflex irritation in the alimentary 
canal or to dentition. 



540 Diseases of the Nervous System 

'Head-banging ' in children has been described by Dr. S. Gee. It con- 
sists in a peculiar habit, to which some children are liable, of turning over on 
to their face at night and banging their heads into the pillow. Dr. Gee 
records three cases : two of these were two and a half years of age, and one 
was five years. One child used constantly, nearly all night, to bang his 
forehead into his pillow. No cause was found to account for this strange 
habit. It appeared very intractable, but one child much improved whilst 
living in the country. 

Hysteria. — Functional nerve disturbances, in the form of sensory de- 
rangements, paresis, contractures, or eclampsia, are by no means uncom- 
mon in children. Hysteria -when it occurs during early life mostly affects 
girls, but it occurs also in boys ; the approach of puberty is the most common 
period. 

A tendency to hysteria runs in families, and is transmitted from parents 
to children, but the foolish way in which children are often brought up, their 
weaknesses pampered and their ailments intensified by injudicious sympathy, 
often tends to aggravate an hereditary disposition to nerve disorders. 
While it most frequently happens that hysterical children come of neurotic 
families and belong to the well-to-do classes, yet such children may be 
found in country districts among country folk, where neurotic tendencies 
might be least expected. ' Fasting girls ' who have had a temporary notoriety, 
'cataleptics,' and religious maniacs have been found in cottage homes and 
among surroundings that one would have supposed were little likely to foster 
hysterical affections. 

Hysteria in its milder or severer forms is often associated with other 
diseases, such as epilepsy, chorea, and various mental affections ; it may also 
be engrafted on to organic brain disease, such as meningitis or some spinal 
affections. Hysterical phenomena are rare before the age of six years and are 
most common about puberty, especially in those cases where menstruation 
has failed to become established. 

Symptoms. Sensory Disturbcmces. — Perhaps the most common form 
of hysteria in girls is hyperesthesia ; there is a complaint of tenderness 
or pain which cannot be accounted for except by a neurosis. There is some 
local tenderness about the spine or one of the joints, especially the hip, the 
girl screaming with pain when the joint is moved ; the thyroid gland or 
front of the larynx is sometimes hypersensitive. Headaches are very common : 
these may be frontal or occipital, or may take the form of the ' clavus ' ot 
adults. Hysteria is apt to mimic various diseases which are normally 
accompanied by severe pain, such as peritonitis, pleurisy, rheumatism ; it 
must, however, be always borne in mind that there may be some actual 
disease present, and that the sensory disturbance is only an exaggerated 
condition of what would normally exist. 

Anaesthesia is much less common in children than hyperesthesia ; but 
hysterical hemianaesthesia, in which the special senses are involved, occa- 
sionally occurs. Sleeplessness is not uncommon, the patients asserting that 
they cannot sleep, and only perhaps dozing off when it is time to get up. 

Motor Disturbances. — Paralysis, or rather paresis, is common ; the larynx 
is perhaps most frequently affected, but paraplegia is not infrequent. Hys- 
terical aphonia in girls has the same characters as in adults : there is loss 



Hysteria 



541 



of voice, the patient always speaking in a whisper ; sometimes the voice is 
entirely lost. 

Paraplegia may come on suddenly after a convulsion, or the legs may 
gradually give way under the child, until she can no longer stand, and is 
therefore confined to bed. There may be loss of sensation, but in our 
experience this is uncommon. The loss of power is never complete : the 
patient moves the legs in bed, and often some attempt will be made to 
stand with help, or she may draw up the legs to prevent them touching the 
ground, and will sink to the ground rather than support her own weight. 
The electrical reactions are normal, 
and usually the knee-jerk is also 
normal, and there is no ankle-" 
clonus. In other cases, more 
especially those which have lasted 
some time, there is more or less 
tonic contracture of the legs ; the 
hip and knee joints are semi- 
flexed, and the foot takes the 
position of equino-varus. In this 
condition, if the spasmodic con- 



may be excessive knee-reflex, and 
ankle-clonus may be present ; if 
there is marked contracture, no 
knee-reflex can be obtained on 
account of the rigid contracture of 
the opposing muscles. The con- 
tracture is present during sleep, 
but usually goes off w T hen the 
patient is under chloroform. 

Hemiplegia is perhaps less 
common. In one of our patients, 
a girl aet. seven years, there was 
a history of a fright from a cat 
jumping on her bed ; immediately 
after the right arm and leg were 
affected. The elbow became bent, 
the wrist flexed and fingers bent 
over the thumb ; the right leg was 
similarly affected, but in less degree 




-Hysterical Spastic Hemiplegia. 



The flexor muscles were in a constant 
state of spasm, except during sleep, when they were relaxed (see fig. 115). 
When the girl's attention was directed away from herself, she would use 
the arm to some extent, raising her hand to her mouth or head. 

In hysterical paraplegia there is no incontinence of urine or fasces ; this 
is certainly the rule, but retention of urine will occur, and in some conditions, 
such as ' hysterical chorea,' both urine and faeces will at times be passed 
involuntarily. We have seen on various occasions girls who were suffering 
from hysteria, simulating hip disease or peritonitis, pass their w r ater in 
bed, so that the bed and linen have been saturated with stinking urine, rather 



54 2 Diseases of the Nervous System 

than use a bed-pan, as they were afraid of being moved on account of the 
pain it caused. In such cases bedsores may form and the patient become 
emaciated. 

Convulsive Attacks. — These are of the usual hysterical type. There 
is a fit of screaming or crying or violent laughter, tonic contraction of the 
muscles, more especially of the back, so that opisthotonos is produced ; the 
arms and legs are dashed about, and the head perhaps made to strike the 
pillow or bed violently. The patient remains conscious during the attack, 
and she rarely injures herself, and the tongue is not bitten. The so-called 
4 hysteroid ' fits have already been referred to (p. 528). 

Mental Symptoms. — Hysteria is closely allied to some forms of insanity, 
and various forms of hysterical insanity occur in girls about puberty. One 
of the commonest of these is a refusal of food. The girl's appetite becomes 
poor, she gradually grows thin, and this excites the sympathy and alarm of 
her friends. The morbid craving for sympathy becomes intensified. She 
resists all their entreaties to take food, and clenches her teeth when it is 
offered, or only takes the smallest quantities, and frequently is guilty of 
deceit, concealing food in her clothes. She gradually wastes till she becomes 
a perfect skeleton, the skin is rough and harsh, the abdomen flattened, and 
the breath foul. Bedsores not infrequently form. In other cases, though re- 
fusing all food at meal times, she will surreptitiously obtain cakes or confec- 
tionery, which she will eat readily. In some of these cases there is melan- 
cholia or eclampsia. Morbid conscientiousness is sometimes present ; the 
girl perhaps takes away marks from herself at school, or accuses herself of 
having told untruths or of having stolen her schoolfellows' things. 

Vomiting and spasm of the pharynx are not uncommon ; one or other 
of these may be present for months and lead to wasting. Usually the food 
returns at once or within a few minutes of taking. Sometimes the food will 
be retained, but there is nausea and retching. 

Diagnosis. — The first step in diagnosis is necessarily to attempt to exclude 
organic disease, which hysteria so often mimics. In sensory hysterical dis- 
orders, such as headaches, and in various forms of paralysis, the question 
is whether or not there is cerebral or spinal disease. Probably the com- 
monest mistake is to assume that organic disease exists when the condi- 
tion is one of hysteria only ; but, on the other hand, we have known the 
symptoms in the early stages of a cerebral tumour attributed to hysteria. It 
is often necessary to wait before a definite diagnosis can be arrived at. But 
it is always necessary to bear in mind that an organic lesion may exist and 
yet undoubted hysterical symptoms be present. 

Treatment. — The treatment of hysteria in its various forms is principally 
moral. The management of the patient must pass from the parents to a 
suitable nurse, or, better still, the patient should be removed to hospital or into 
lodgings away from her friends. If once the child is under firm control, is 
deprived of the morbid sympathy it craves for, and is at the same time en- 
couraged to put forth all its voluntary power, an improvement in its condition 
will immediately begin. In cases of paralysis, in addition to isolation from 
the parents and all sympathising friends, massage and faradisation are of 
much advantage. The patient must be made to use the weakened limbs in 
moderation, and encouraged to believe that they will get entirely well. 



Headaches 543 

In less severe cases change from city to a healthy country life is of great 
importance. Life at a farm with its many outdoor attractions and occupa- 
tions is perhaps the best adapted for hysterical children. Effort must be 
made to interest them in many things outside themselves in order to break 
the vicious habit of dwelling inordinately on their own feelings and ailments. 
In many of these cases the general health is poor and menstruation delayed. 
In such, iron in the form of bromide of iron, as in Fletcher's syrup, is useful, 
while the bowels should be regularly acted on by small doses of aloes, or some 
mineral water such as Rubinat or Hunyadi Janos. 

Headaches. — Children, especially girls of seven years of age on to 
puberty, are very liable to headaches, sufficiently severe to lay them up for 
part of a day or perhaps longer. These headaches may arise from various 
causes, and it is important to try, if possible, and ascertain their origin ; 
diagnosis is frequently by no means easy, as pain is referred to the forehead 
in many different morbid states and conditions. Frontal headache is by far 
the commonest form of reflected pain. It is important in the first place to 
exclude hypermetropia as a cause of frontal headache. Straining the accom- 
modation of the eyes, especially when the subject is below par, may give rise 
to frontal headache, aching being referred to the eyeballs, while at the same 
time, when an attempt is made to read, the letters run together and the 
eyes easily water. A diagnosis is easily made with the ophthalmoscope, 
examining the retinal vessels by the direct method, as well as by the use of 
test types. 

Headaches are very common in rapidly growing children, who are, to 
use an ordinary expression, ' outgrowing their strength.' Such headaches 
may be due merely to weariness or to the irritable state of the nerves which 
comes on when over-tired or fagged ; or they may be due to anaemia or 
dyspepsia. The latter is probably the most frequent cause. The appetite 
may be good or capricious, more food is taken than the digestive organs can 
cope with, and dyspepsia or a subacute gastric or intestinal catarrh is the 
result. A sick headache is complained of, the child looks heavy and dark 
about the eyes, there is nausea or actual vomiting, perhaps some fever, and 
it takes a day or two to regain the ordinary state of health. Headaches due 
to overwork of the eyes and brain are especially common in schoolboys and 
girls when preparing for examinations and taking too little exercise and re- 
creation. With the headache there is often sleeplessness at night, anaemia, 
and more or less dyspepsia. There is usually no difficulty of diagnosis here, 
as the history of the case will render its nature plain. 

There is a form of headache which is by no means uncommon, which is 
distinctly neurotic, and which does not appear to be connected in any way 
with dyspepsia, sluggish liver, overwork at school, or organic disease. The 
child is usually a girl of ten or twelve years of age, who suffers with a severe 
headache, often accompanied by sickness, once or twice a week, perhaps 
oftener, which comes on at irregular times, and is sufficiently severe for her 
to take to bed or to lie on the sofa for most of the day, and to incapacitate her 
for all work or play. Such headaches are made worse by noises and exer- 
tion ; at times there is violent sickness or retching, and perhaps giddiness in 
the erect posture. The bowels are usually constipated, the tongue clean, and 
in the intervals between the attacks the child is in g"ood health and able to gro 



544 Diseases of the Nervous System 

to school and take moderate exercise. The causes of such headaches are very 
difficult to discover ; a tendency to such is often hereditary, and, while worse 
during' the period of puberty, the tendency may remain throughout life. 
They are often very obstinate, and medicine fails to relieve as long as the 
patient remains at home, leading a sedentary town life ; they are almost 
always better during the holidays spent away at the seaside, or whilst lead- 
ing a healthy country life, but recur again when a return is made to town 
life, with school and the ordinary home routine. 

In some other cases the headaches are more distinctly hysterical, the 
pains being described as of a ' shooting ' or ' boring' character, and coming 
on when the spirits are depressed or when there is some unpleasant duty or 
distasteful study to be undertaken. On the other hand, all headaches are 
forgotten if the patient is roused by some excitement or the prospect of some 
unusual pleasure. When the headache is present, the patient demands the 
sympathy of all her friends, and is apt to lapse into a chronic invalid, 
expecting to receive the commiserations and attentions of the whole house- 
hold. She objects to exertion of any kind ; the least noise or loud talking 
brings on the headache. The appetite perhaps becomes poor, she becomes 
thinner, and the whole health suffers, or, on the other hand, in some cases 
the appetite is not affected. These hysterical headaches are commonest at 
or about puberty, when menstruation is commencing, but they may be 
present in boys and in girls of nine or ten years of age. 

The most important question in connection with diagnosis is with regard 
to the presence or absence of organic disease. Are tubercles forming in the 
meninges of the brain? Is there a cerebral tumour, or are the headaches 
either reflected from the digestive system or purely nervous in character ? 
The diagnosis between cerebral disease and functional disease is usually not 
difficult if the history given by the friends can be relied upon, or if there is an 
opportunity of watching the patient for a few weeks. The headache accom- 
panying the early stages of tubercle of the meninges is associated with 
irritability, wasting, hectic fever, loss of appetite, shivering, and cough ; and 
a few weeks more or less will almost certainly see developed more marked 
cerebral symptoms, such as squint, vomiting, and involuntary passage of 
faeces. The headache due to cerebral tumour is mostly constant, though 
worse at times than at others ; it is always made worse by movement ; there 
are erratic and apparently causeless vomiting and optic neuritis. 

In all cases of persistent headache it is necessary to frequently examine 
the optic discs for any evidence of optic neuritis. We have known several 
cases in which headaches were after awhile accompanied by optic neuritis 
followed by loss of sight and without any definite cerebral symptoms — the 
headaches getting w r ell in the course of many months, but there was blindness 
from optic atrophy. 

Treatment. — The treatment of headaches is naturally directed to moving 
the cause. In rapidly growing children it will mainly consist in the 
avoidance of over-exertion or fatigue, and in ordering a very moderate 
amount of brain-work, a healthy country life, and a careful regulation of the 
diet. The digestive organs are probably being given more work than they 
are able to perform, a gastric or intestinal catarrh is set up, and the disordered 
state of digestion is expressed by a frontal headache. Vomiting in these 



Headaches 545 

cases nearly always relieves the headache ; if it does not take place, perhaps 
there may be feverishness, nausea, and headache for a day or two. When 
these headaches are coming on, the simplest and best remedy is an emetic 
such as a teaspoonful or two of ipecacuanha wine, to be followed by a little 
judicious starvation or the lightest possible diet for a few days. For the 
avoidance of such sick headaches meat should be allowed only in moderate 
quantities, it must be well cut up and masticated slowly, and care should 
be taken to regulate the bowels from time to time with some effer- 
vescing citrate of potash, Rubinat or Carlsbad water, before breakfast. In 
the neurotic forms of headache, arising independently of digestive derange- 
ments, the treatment is often very unsatisfactory. When the attack comes 
on, and is evidently severe, bed is the best place, with a wetted handkerchief 
to the head in the hope of getting the child to sleep ; coffee, effervescing 
citrate of caffein (1 to 2 grains of the pure salt), monobromide of camphor 
(1 to 2 grains), ext. guaranaeliq. (10 to 15 drops), ext. cannabis indicae, or bro- 
mides are often beneficial. Phenacetin (2 to 5 grains) has been used with 
good effect. In the intervals between the headaches the most important 
treatment relates to regulating the bowels and to insisting on a simple but 
nutritious diet. In some cases good has followed the entire avoidance of 
butcher's meat (Haig). A healthy country life or change of scene is often 
of the greatest service and generally effectively cures, for a while at least. 
In hysterical headaches the patient should be encouraged to take an active 
interest in some work or play. 

night terrors. — These attacks are allied to hysteria and are common 
in neurotic girls and boys. The child, who has perhaps been sleeping 
quietly for a few hours, suddenly sits up in bed, its face the picture of horror 
and fright, while it shrieks and points at some imaginary object. The 
appearance of the friends on the scene does not pacify it ; it cannot be 
aroused, but continues to be affrighted by some apparition. After awhile it 
wakes up or goes off quietly to sleep again, and in the morning knows 
nothing of the night's disturbance. These attacks occur several times during 
the same night or there may be weeks without an attack. Whenever night 
terrors occur, the child's diet should be carefully regulated, especially as 
regards the evening meal. Any indigestion should be treated ; a dose of 
bromide at night may be given. The prognosis is good. 



N N 



546 Diseases of the Nervous System 



CHAPTER XXV 

DISEASES OF THE NERVOUS SYSTEM — continued 

Speech Anomalies 

DURING the first year of life the infant is unable to express itself by means 
of intelligent speech, nor does it make much progress in the understanding 
of spoken words. A cry is the first sound uttered by the infant ; it is a 
reflex act, the stimulus being some form of discomfort or pain. Within the 
first two months (five weeks, according to Preyer) variations in the tone and 
strength of the cry occur, indicating acute pain or hunger or impatience. 
Later still the cry becomes more distinctive and expressive, and the cry of 
anger or disappointment may be distinguished from the cry of hunger. 
Smiling may be observed by the end of the second month or earlier (twenty- 
third day, Preyer), but really noisy laughter is not heard till several months 
later. Other facial expressions, such as frowning, rage, sulkiness, are 
noted later in the first year. From the earliest months the infant ' babbles ' 
or ' crows' when pleased or in a good humour ; this doubtless is a sort of 
instinctive exercise of the speech organs. It seems to take a pleasure in 
exercising its organs of speech, in much the same way that it derives plea- 
sure from lying on its back and kicking vigorously in an aimless sort of way. 
Both consonant and vowel sounds are produced in great profusion, but in an 
irregular and inco-ordinate fashion. Preyer noticed that in one of his babies 
all the vowel sounds and all the consonant sounds were used during the first 
seven months except w, s, z,f, and sh ; all the latter were postponed till the 
second year. By the end of the first year some of the easier consonant 
sounds, such as mam-mam, ba-ba, dada, nana, are repeated in a meaningless 
sort of way, but before long they are applied to persons and things. Some 
of the earliest sounds acquired are those made by domestic animals, and the 
child quickly uses the sound to name the animal. The understanding of 
spoken words precedes by some months the ability to express ideas in 
language. In answer to a question the child will use ' gesture language ' in 
preference to articulate speech. It will point to the object named or express 
assent or dissent by nodding or shaking its head. Many feeble-minded 
children, and also many of the lower animals, as the dog, will understand 
spoken words, but have not the power of expressing ideas in words. During 
the second year the vocabulary increases fast, the child quickly imitating 
and repeating the word it hears, so that by the end of the second year it not 
only uses a number of words correctly, but can string a few nouns and 
adjectives together, and has learned the meaning of short phrases. Thus 



Defects in Speech 547 

we find such short sentences used as ' Kennie come i?i mutnmy*s bed,' or 
1 Kennie no liky pudding? At this period, and for the next year or two, 
words are indistinctly or improperly pronounced, with a tendency to clip 
them short or to drop consonants. Some consonants present greater 
difficulty to the young child than others, and are constantly dropped out of 
words ; thus s, especially when it precedes-another consonant, is omitted, as 
cool for school, kwek for squeak, no for snow. Difficulties often arise with 
the th and sh : Ruth becomes Roof \ the vibratory consonant r is a great 
stumbling block, and the distinct pronunciation of it is, perhaps, never 
acquired : grub is apt to become gzuub, and roof, woof 

To learn to speak intelligently there must be : 

{a) A perfect hearing apparatus to transmit the vibrations of sound to the 
auditory centre. 

(6) An auditory centre which translates vibrations of sound into ideas. 

(c) ' Think organs ' or perceptive centres. 

(d) Motor speech centre (Broca's convolution). 

(e) Speech apparatus for converting motor impulses into articulate 
speech. 

Some children are more backward in talking than others, and are at the 
same time behindhand with walking and cutting their teeth, and it is only 
after the end of the second year is passed that they begin to make progress. 
This frequently happens with rickety children, or with those who have had 
some serious disease to contend with. Other children not only do not begin 
to talk when the usual time arrives, but as months and years go on make no 
attempt, or their articulation is indistinct and imperfect for their age. In 
another but smaller class the child learns to talk fairly well or imperfectly, 
then an illness comes on and it loses the power of speech. The principal 
causes of imperfection or absence of speech may be tabulated thus : 

1. The child may be deaf ; it is mute because it is deaf (a). 

2. The child does not speak distinctly, there may be some defect in the 
organs of speech (e). 

3. The child is feeble-minded, the ' think ; organs are at fault (c). 

4. There is motor or auditory aphasia (b or d). 

5. There is hesitancy in speech due to 'stammering.' 

1. Deaf-mutism. — Deaf-mutes are those who cannot speak because they 
cannot hear : the deafness may be due to congenital defect, or the}- may 
become deaf through illness before they have learnt to talk ; as a rule, if the 
child becomes deaf before he is seven years of age, dumbness results. The 
congenital variety appears mostly to be the result of hereditary taint, con- 
genital deafness having occurred previously in the same family. It is 
doubtful if the marriage of cousins has anything to do with it. The morbid 
anatomy is very uncertain, as there are but few post-mortem records of such 
cases ; in such cases there is reason to believe that congenital deafness is 
the result of inflammation of the internal ear during intra-uterine life or a 
failure of development of certain nerve centres. How early is it possible to 
detect deafness ? The diagnosis is necessarily very difficult during the first 
few months of life, especially when we remember that congenital deafness is 
rarely complete, the ringing of bells, whistling, &c, being heard when the 
ear is quite incapable of detecting articulate sounds. During the first few 



548 Diseases of the Nervous System 

weeks after birth the healthy infant gives no response or signs of recog- 
nising sounds, but loud noises will wake it up. It is only during the third 
or fourth month that the infant appears to recognise sounds and voices, 
but, as some infants are more backward than others with regard to percep- 
tions, it is only after six months of age, or from that to a year, that a definite 
knowledge can be come to with regard to deafness. When the infant is a 
year old, and has never uttered an articulate sound, while it shows no want 
of intelligence in other ways, and its muscular power and growth are in 
accordance with the normal standard, there is strong reason to believe that 
its speech defect is due to deafness. The diagnosis between a failure to 
speak due to partial deafness or failure on account of mental feebleness is 
often extremely difficult, perhaps, in certain cases, for a time impossible, in 
the absence of other signs of mental defect. The infant may be tested by 
means of a loud whistle, bell, or clapping hands, care being taken that it 
cannot see the performer, while its face is watched for any sign of recognition 
on its part. A confident opinion cannot well be given before the sixth month. 
Parents will often not detect deafness till the child is much older than this. 
On the other hand, parents will constantly assert that a feeble-minded infant 
is deaf or blind. 

In the following case the diagnosis was very difficult at first : 

Annie M. C, 2 years 9 months. First child, healthy infant, took notice in the usual 
way at 2 or 3 months of age, sat up at 6 months, late in walking at 15 or 16 months. She 
' jabbered ' and ' babbled ' like any other infant ; at 9 or 10 months said ' dad dad,' ' mam 
mam,' ' bob bab ; ' at 12 months said ' dada, dada,' ' ya, ya,' ' mam, mam,' and later called 
her cousin ' Sam ' ' am, am.' Some difficulty in teaching her cleanly habits. The child 
when tested is absolutely deaf, cannot hear loud whistles or voices. 

Presumably the articular sounds made by this child were the result of 
' instinct ' aided by watching the lips of its friends. Many deaf-mute children 
seem to delight to make shrieking or other unpleasant noises with their 
vocal organs. 

Acquired Deaf-mutism. — When a child under seven years loses its 
hearing in consequence of disease, its speech becomes indistinct and more or 
less unintelligible, and it loses the power of speech altogether, either quickly 
or gradually, according to its age and intelligence. The loss of speech will 
necessarily depend to some extent upon the amount of deafness. According 
to Hartmann, it is possible, if the child is intelligent, and great care is taken 
to correct its mistakes in talking and to induce it to talk, that speech may be 
retained. 

The lesion which commonly produces deafness is an inflammation of the 
labyrinth, either idiopathic or secondary to meningitis, scarlet fever, typhoid, 
or whooping cough. The difficulty of distinguishing between acute otitis and 
meningitis has already been pointed out (p. 475), and consequently the 
extent to which deafness is produced by one or the other is uncertain. 
Attacks of cerebro-spinal meningitis undoubtedly frequently produce deaf- 
ness, as does also scarlet fever. In this country scarlet fever plays a more 
important part than other diseases in destroying the auditory apparatus. 
Hartmann believes that an inflammation of the labyrinth and consequent 
injury to the terminal apparatus of the auditory nerve, and not suppuration in 
the middle ear, is the cause of deafness ; though the latter frequently takes 



Defects in Speech 549 

place, it is not necessarily present. A nasopharyngeal catarrh seems to be 
an occasional cause of labyrinthine disease. 

The hearing power of deaf-mutes is usually tested with a bell and 
tuning-fork, the two ears being tested separately. Statistics collected by 
Hartmann show that in 865 cases of deaf-mutism in different institutions 60 
per cent, were totally deaf, about one-fourth (24-3 per cent.) heard sounds 
such as the ringing of a bell, while 15 per cent, heard words or vowel sounds 
when pronounced loudly close to their ears. 

2. Physical Defects inthe Mouth. — Parents not infrequently bring a 
child to consult a medical man with regard to his backwardness or indis- 
tinctness in speech, which is attributed to his being tongue-tied or to some 
deformity of the mouth or palate. In the majority of such cases no physical 
defect can be detected, the defect being rather in the nervous mechanism 
of speech. It is quite conceivable that a more than usually attached fryenum 
may be present and interfere, however slightly, with the movements of the 
tongue, and explosives of the second stop position, /, d, s, are badly pronounced. ' 
A highly arched or deformed palate may render speech imperfect, the child 
speaking like one with cleft palate ; but it must not be forgotten that weak- 
minded children often have high palates, while their defective speech is due 
to mental feebleness. Defective speech is also present in those with large 
tonsils and post-nasal adenoids ; there is a characteristic 'stuffiness' about 
the voice, and difficulties with the nasal resonants m, n, ?ig, inasmuch as in the 
pronunciation of these the air is allowed to escape through the anterior nares. 
Paresis of the soft palate may be present, especially after diphtheria, the 
voice having a nasal twang and difficulty being experienced in pronouncing 
the explosive labials p and b, as the air escapes into the nasal cavity, the soft 
palate failing to act. 

3. Mental Defect. — Perhaps the commonest form of defective speech is 
connected with the nervous mechanism. The child perhaps appears intelli- 
gent and bright, no defect can be discovered in the mouth, yet his pronunci- 
ation of certain sounds is defective, as if he had not perfect control over 
his lips, tongue, and vocal cords. He may have especial difficulty with the 
consonants of the third stop position, as k and g, while the fricatives th 
and r are often great stumbling-blocks. Backward children, or those of 
intelligence below normal, are especially apt to have difficulties in pronuncia- 
tion, in other cases the intelligence is fully up to the average. The fault lies 
presumably in Broca's convolution. A boy of eight years whom we 
examined used the vowels fairly well, but the only consonants he used were 
fi, m, ?, n, and w ; Sam Brown was ' Pam Pown ' &c. ; he could add up 
simple sums, and write his name, but he was generally backward. He could 
not pronounce consonants requiring voice, as b, d. All degrees of difficulty 
of speech may exist : it may be so marked that the child avoids conversation 
as much as possible, and expresses his assent or his wants by signs. This 
form of difficulty of speech is often hereditary. It is possible that in some of 
these cases the hearing is at fault and the child suffers from partial word- 
deafness, in a similar way to a child suffering from colour-blindness, or a 
faulty development of the co-ordinating motor centre of speech. Some 

1 See 'Some Forms of Defective Speech,' Warrington Haward, Lancet, vol. i. p. in, 



550 Diseases of the Nervous System 

children talk a sort of gibberish which perhaps their brothers or sisters under- 
stand, but no one who has not been with them a great deal can make out. 1 

If, however, instead of imperfect speech the child of five or six years of 
age does not talk at all, there is probably some mental defect, the child fail- 
ing to understand what is said, or although it may understand the speaker, 
yet there is a failure in the process of converting thoughts into words. 

4. Aphasia. — Children, like adults, may suffer from aphasia due to 
organic disease, or from a functional aphasia. In the former the aphasia 
may be the consequence of embolism of the left middle cerebral artery, and 
be associated with a right hemiplegia, or a tubercular tumour may compress 
the left third frontal convolution. 

Functional aphasia is not uncommon and occurs usually after exhausting 
fevers ; as, for instance, in typhoid after the febrile stage is passed many 
months may elapse before the child speaks. It may occur after pneumonia ; 
thus a child of two and a-half years suffered from inflammation of the lungs 
in October ; his mother said his talking left him while getting better. He 
did not speak a word till the following April, when he said ' Drink ; ' the 
following month he began gradually to talk again. (See also case, p. 520.) 

In another case, kindly sent us by Dr. Hodgson of Oldham, a boy aged two 
and a-half years had whooping cough and was convulsed continuously for four 
hours; he talked as usual for a day or two after this attack, then ceased to talk, 
though once in his sleep he said ' mamma.' He expressed assent when 
spoken to and pushed his plate if asked if he would take more food ; he 
appeared to understand what was said to him. He remained in this state 
without saying a word for two months, then he said a word or two and a day 
or two after completely regained his speech ; and shortly became as great 
a chatterbox as ever. A boy under our care with spastic paralysis (see 
fig. 105) could not speak or make anyone understand except by signs, and 
if asked his name he pointed to his name written on his bed card or on the lid 
of a toy box. 

The power of speech is lost suddenly at times in consequence of a nervous 
break-down. Dr. Langdon Down records the cases of two brothers, who had 
spoken well and understood two languages, completely losing the power of 
speech at the period of the second dentition. 

5. Stammering- occurs occasionally before the period of the second den- 
tition ; it is often hereditary, and is always worse during a period of ill health. 
Boys are far more commonly affected than girls. It is especially apt to 
supervene in boys who are overworked at school, and who inherit neurotic 
tendencies. 

Treatment of Defective Speech. — The treatment necessarily depends en the 
cause of the defective speech. Surgical treatment may be required in the 
first place , enlarged tonsils must be excised and post-nasal adenoids removed, 
defects in the hard or soft palate must be remedied as far as possible by sur- 
gical and mechanical means. Special instruction in articulation, especially 
directed to the difficult sounds, must then be practised. For this purpose 
the teacher faces the pupil, showing him by exaggerated movements of his 
own lips, tongue, or larynx the positions they should assume to form the 

1 See Dr. W. B. Hadden, 'On Certain Defects of Speech in Children,' Journal of 
Mental Science, January 1891. 



Defects in Speech 5 5 1 

desired sounds, and practising the pupil in these movements. In fact, the 
oral method now so commonly in use for the instruction of deaf-mutes 
must be practised in all cases of defective speech. In habitual stammering 
the child, if old enough, should be tested (see ' Physiological Alphabet ' 
Appendix) to ascertain the chief stumbling-blocks among the consonants. He 
should be taught to speak slowly, and practise the consonants over which he 
hesitates. Breathing exercises are also useful. 

The education of deaf-mutes has received much attention of recent years, 
more especially in Germany, and schools are now established throughout the 
country where the education of deaf-mutes is carried on on the oral system. 
By this system the senses of sight and touch are made as far as possible to 
take the place of the defective sense of hearing. 

If the patient has become deaf after he has learnt to speak, everything 
must be done to assist him to retain the faculty of speech and to discourage the 
use of sign-language. The child must be encouraged to speak, the words 
that are wrongly pronounced being corrected as far as possible by showing 
the child the exact position of the mouth, lips, tongue, or larynx, and by 
making it repeat the word until it has pronounced it correctly. New words 
are taught in a similar manner, and by showing the child the objects, or 
pictures of the objects, taught. 

The instruction of congenital deaf-mutes is most usefully commenced at 
six years of age ; before this time it is difficult to fix the child's attention for 
sufficiently long together ; indeed, many children do not manage to learn 
much till they are seven years of age. It need not be said that the training 
of deaf-mutes in the use of oral language is a tedious and difficult process, 
requiring a special training and much patience on the part of the teacher. 
The deaf-mute has not only to learn to speak, but also to understand what 
is said to him by watching the movements of the speaker's lips. After many 
years of training the clever deaf-mutes are able to leave school and converse 
with others sufficiently to enable them to learn a trade and earn their own 
living. 1 Their speech is necessarily laboured, each syllable is emphasised 
and the tone disagreeable ; we, however, know one boy of sixteen years of 
age who has been completely deaf since four years of age who speaks really 
well and with a Lancashire accent ! He was taught by the oral method at 
the Old Trafford Schools, Manchester. 

Mental Affections in Childhood 

All degrees of intellectual feebleness are met with during infancy and 
childhood, ranging from complete amentia, the result of an ill-developed or 
damaged brain, to mere backwardness or dulness of the mental powers. 
The classification of such is roughly made when we speak of idiots, imbeciles, 
mentally feeble and backward children, though in using these terms it must 
be borne in mind that no sharp line can be drawn between idiots and 
imbeciles, and mentally feeble ; moreover, there are objections to both terms, 
inasmuch as the one is a term of reproach and the other is frequently applied 
to those who are the subjects of senile dementia. The terms ' feeble-minded ' 

1 For details of the methods of oral instruction, see Deaf-mutism, by Hartmann 
(Cassell's translation). 



552 Diseases of the Nervous System 

and 'mentally-feeble' are usually applied to children who, while not being idiots 
or imbeciles, have mental powers below the average, and are in consequence 
not able to take their places in school with normal children, but require 
special education. The term ' defective ' children includes those of feeble 
mental powers and also those of normal mental power, who by reason of 
physical defects cannot be taught in elementary schools by ordinary methods. 1 
The term backward children rather applies to children of slow mental 
development, or who are mentally slow and d.ill for their years. 

No classification of idiots in our present state of knowledge of pathology 
is quite satisfactory, the classes being certain to overlap. We will speak of 
the following groups : 

i. Congenital idiocy. 4. Backward children. 

2. Developmental idiocy. 5. Syphilitic idiocy. 

3. Accidental or acquired idiocy. 6. Cretinism. 

1. The congenital group includes by far the largest class, those in 
whom some mal-development, or arrest of development of brain or some 
brain-damage takes place during intra-uterine life, and who in consequence 
are never in possession of average intellectual powers. The members of 
this group usually show within a few T months of birth that they are not like 
ordinary children. The mother notices that the infant when a month or 
two old does not take notice as it should do ; it pays no attention to a bright 
light or sound, it does not recognise its friends by a smile, or appear to hear 
its nurse's voice. As time goes on it makes no attempt to sit up or hold 
toys in its hands, its muscular system is weak, and its face wears a vacant 
expression. At a year or eighteen months old it has made no progress in 
walking or in using its limbs, or perhaps it cannot utter any articulate 
sound ; it slavers continually, the saliva running from its mouth onto its 
frock, and it has no control over its urine and faeces. As its muscular 
power gradually increases, it learns to walk, perhaps to say a few words, 
and, if carefully looked after, to become more cleanly in its habits. At three 
or four years of age it cannot understand anything that is said to it, it 
takes no notice of anything in its daily walk, and can only utter one or 
two articulate sounds. Often such children are uncertain in their temper 
and mischievous. 

The physical characters as well as the degree of intelligence possessed 
by congenital idiots are very various. They mostly have coarse, harsh skins, 
slow circulations, and suffer from constipation. They are exceedingly apt 
to suffer from various tubercular manifestations. They nearly always remain 
stunted in growth. Congenital idiocy may be associated with a peculiar 
formation of the skull, corresponding roughly to the configuration of the 
brain inside ; while some crania are small, it must not be supposed that 
small heads are constantly present in congenital idiots ; in some cases the 
head is symmetrical and well-shaped, and of average size. Congenital idiots 
may have microcephalic (Aztec type) or small heads, macrocephalic or 
large heads, dolichocephalic or long heads, brachycephalic or broad heads. 
Sometimes there is a want of symmetry on the two sides of the cranium, or 

1 See Report of the Departmental Committee on Defective and Epileptic Children. 



Congenital Idiocy 553 

there is a deficient development of the frontal or occipital region. Various 
conditions of the mouth found in congenital idiots have been especially 
emphasised by some authors ; these, it is needless to say, are not univer- 
sally present. The palate is inordinately high and arched, or more decidedly 
V-shaped, and often unsymmetfical ; the tongue is usually large, and its 
movements are apt to be badly co-ordinated and awkward : the fungiform 
papilla? are hypertrophied ; the mucous membrane of the pharynx is apt to 
be thickened and congested, the tonsils hypertrophied, and post-nasal 
adenoids may be present. Slavering due to paresis of the muscles of the 
lips and tongue, as well as to the hypertrophy of the glands of the mouth, 
is very common. The late Dr. Langdon Down looked upon slavering as of 
some diagnostic importance, being nearly always connected with mental 
feebleness. The teeth are late in appearing and quickly become carious. 
The semilunar or epicanthic folds are often present at the inner canthi of 
the eyelids, the eyes may be set too close together or too widely apart, there 
may be strabismus, nystagmus, or coloboma iridis present. The position 
and shape of the ears are worthy of attention ; they may be large and stand 
out from the head, may be planted abnormally far back, be abnormally 
adherent, or the lobule defective. It must be borne in mind that while there 
has been an arrest of the development of the brain, other malformations may 
also be present, such for instance as cleft palate, or some malformation of 
the heart, as an open foramen ovale, or imperfect ventricular septum. The 
fingers may be webbed or stunted. We have already noted that nearly all 
congenital idiots have poor circulations, suffering from cold feet and hands and 
chilblains, and it may be added that their sensation is defective and wounds 
of the extremities are long in healing. The fingers may be 'webbed'" or 
stunted. ' The dyscrasia which accompanies or causes genitous idiocy,' says 
W. W. Ireland, ' affects both the constitutional vigour and the symmetrical 
growth of the frame, though not equally in every part. Nature works like a 
bad sculptor, who fails to give the proper form sometimes to one member 
of the body and sometimes to another. There are errors, now here and now 
there ; and some parts are more happily shaped than others. Occasionally, 
however, genitous idiots are strong and good-looking, with well-formed 
heads, good teeth, and no deformities whatever/ 

With regard to the sensory and mental deficiencies of congenital idiots, 
space will not allow us to enter into detail, and the reader is referred to 
special treatises on the subject. 1 Among idiots there are those who live out 
their lives giving but scant evidence of the possession of any intellectual 
powers ; they are absolutely helpless, and would starve if food was not actually 
put into their mouths. They can hardly be said to be conscious, or their 
consciousness is of the indistinct kind ; they heed neither sights nor sound, 
they make no voluntary effort. On the other hand, in some imbeciles there is 
evident talent, if not genius, in some directions, while in other ways at ten or 
twelve years of age they are little else than infants. Thus one boy of seven- 
teen years of age we know, can distinguish Schubert and Beethoven's works 
at once when he hears the music, and can understand both English and 
German in conversation, but he cannot add two and three together or 

1 See Mental Affections of 'Children, W. W. Ireland, 1898. 



554 Diseases of the Nervous System 

recognise a single letter. He cannot dress or even properly Wvx\ himself 
While some imbecile children are exceedingly good-natured and can be 
easily managed, others are very much the reverse. As infants they are con- 
stantly crying without apparent reason, and wear out the patience of nurses 
and mothers. When a little older and able to crawl or walk— though 
always late in doing so — they are everlastingly in mischief. They are not 
still for a moment, and it is at least one person's business to manage them. 
When they cannot have what they want there is an unearthly shriek quite 
unlike a normal child; they will eat dirt or the wool off the blankets, and are 
apt to masturbate. They will bite or pinch or kick or scream for hours if 
not allowed their own way. It is exceedingly difficult to get their attention 
for many moments together. 

There are one or two well-marked varieties of congenital or 'genitous' 
idiocy, and among these the Mongolian type first pointed out by Langdon 
Down is worthy of note. On account of their resemblance to the Kalmuc or 
Tartar tribes of Asia, the name Mongol has been retained. Their appearance 
is, according to Dr. J. Thomson, characteristic at birth, certainly it is in many 
cases at a few months old, as we have had several opportunities of observing. 
The most striking feature is the obliquity of their eyes, the axis of the 
palpebral fissures sloping inwards, the eyelids are habitually half-closed, 
from the drooping of the upper lid, giving them an ' almond ' shape. This 
obliquity of the eyes is often not well seen in photographs if the patient is 
watching the performance. The tongue is large and protrudes partially 
from the mouth, the papillae are prominent, and the mucous membrane 
fissured. The head is mostly rounded, often small ; their hands are broad 
and squat. Mongolian babies are late in holding up their heads, sitting up, 
or learning to walk. They are late in learning to talk and backward in 
bodily development. They are apt to suffer from congenital heart disease, 
and easily succumb if attacked with bronchitis, pneumonia, or scarlet fever. 
Many die of tuberculosis, and only a small proportion reach adult life. 

The child (fig. 116) was a Mongolian idiot who died of pneumonia at two 
and a-half years of age. He could not walk or talk and understood very 
little of what was said to him. His head measured i8£ in. in circumference. 
He did not care much for toys, unless they made a noise. He never smiled. 
His brain was of nearly average weight, 37 oz., the convolutions were fairly 
well marked, and to the naked eye the appearance was normal. 

Another well-marked group of congenital imbeciles is formed by the 
cretins, but these will be described later (p. 559). 

Microcephalic idiots mostly belong to the congenital division, the brain 
having suffered damage during intra-uterine life, or there has been an arrest 
of development. Of the former the case figured (96 and 97) on p. 482 is a good 
example. Microcephaly from arrest of development of the brain in an 
extreme degree is not common, though several remarkable cases are on 
record (Ireland, Shuttleworth, Beach) in which the brain has been examined 
after death. On account of the early closure of the fontanelle, sometimes 
before the fifth month, it has been hastily assumed that the premature closure 
of the skull has prevented the development of the brain and craniotomy has 
been performed with the idea of allowing expansion. Such operations have 
been failures,, inasmuch as they are the result of a mistaken pathology 



Hydrocephalic Idiots 



555 



Microcephalic idiots are mostly dwarfs, and in extreme cases are of very limited 
intelligence ; they are quiet and docile, but capable of very little education. 

Hydrocephalic idiots may belong to the congenital division, the child 
being born hydrocephalic or it may become so after birth. A large propor- 
tion of hydrocephalics die during infancy or childhood; those that survive 
show more or less want of intelligence. In the worse cases there is spastic 
contraction of the limbs and complete dementia. 

Eclampsic Idiocy. — Some infants suffer from eclampsia almost from 
birth, the attacks occurring many times daily ; nearly all such show want of 
intelligence for their years. In post-mortem examination cf the brain of 
such cases we have found nothing as far as naked eye appearances go to 
account for the fits. It is certain, however, that small haemorrhages may 




Fig .ti6. — Joseph B.. aged 2i 3-ears, Mongol Imbecile. 



take place as the result of the fits and other changes secondary to the con- 
stant mechanical congestion of the veins of the membranes of the brain 
taking place. The eclampsia is in reality of the epileptic type, an unstable 
condition of the nerve centres of which we see similar examples in asthma 
and cyclic vomiting. The constant occurrence of fits certainly leads to 
exhaustion of nervous force and dulling .of the intelligence. Eclampsia is 
much more common in all forms of idiocy, excepting Mongols and cretins, 
than in normal children. 

Epileptic Idiocy. — It is not easy to draw the line between eclampsic and 
epileptic idiocy — in other words, between infants who suffer from fits and who 
are more or less imbeciles or mentally feeble, and older children who suffer 
from fits of the epileptic type. In a few cases we find children of the 
highest mental powers who suffer from occasional fits, but on the other 



556 Diseases of the Nervous System 

hand confirmed epileptics usually show sonic mental dulness or mental 
obliquity. Some of the worst forms of idiocy are asso< iated with epil< 
as can be seen by a visit to a large asylum for idiots or to a lunatic asylum. 
Some of the hemiplegic idiots suffer from epilepsy. 

2. Developmental.— -In this group are included those who show no 
marked signs of being wanting in intelligence during infancy, but who during 
childhood or youth may show signs, often suddenly, of a mental breakdown 
and arrest of the development of the mental powers. This change may come 
at any time during childhood, but more especially on the approach of puberty. 
This sudden change often comes as a great surprise to the friends ; the 
child's head is well formed, he looks intelligent, quite unlike the appearance 
of an idiot, and they are at a loss to account for the change, or attribute it 
to some trifling disorder. Sometimes the first intimation of the crisis is that 
the child ceases to talk : such was the case in a little boy seen by us, who 
was perfectly intelligent and bright up to 4^ years, when he suddenly ceased 
to speak and gave over playing with toys, his principal employment being 
to throw his toys on the floor and proceed to kick them about the room ; he 
hardly seemed to know his mother, though at other times he appeared to 
understand. He eventually recovered. 

In pother cases the change comes at the second dentition or at puberty : 
such children are apt to be morbidly conscientious, believe they have told 
lies or stolen, or, on the other hand, they become wayward, mischievous, 
unkind to their brothers and sisters, and disobedient. (See Hysteria.) 

Epileptic fits are apt to appear at this period. Dr. Langdon Down has 
noticed that these cases often have a scaphocephaly head, which is ' prow- 
shaped' anteriorly, the prow corresponding with the inter-frontal suture, 
which forms a prominent ridge. Such cases, according to this author, are 
apt to break down by over-pressure at school or from over-excitement during 
childhood. 

3. Accidental or Acquired. — To this class belong those who do not 
inherit any insane tendency, and who would become healthy, intelligent 
children but for some accident which damages the brain at birth, or some 
lesion at a later period. Reference has already been made to cases of post- 
partum paralysis (see p. 502) due to meningeal haemorrhage occurring during 
birth ; such are often not only paralysed, but mentally feeble. There is strong 
reason to believe, as already stated, that damage done to the convolutions 
on the surface of the brain by a meningeal haemorrhage when an infant is 
in a condition of asphyxia is the cause of the feebleness of intellect, and 
possibly such cases may escape paralysis, the motor centres escaping damage. 
In another class of case the infant is quite well, and its development is satis- 
factory, till it has some acute illness with cerebral symptoms, mostly during 
its second year. This may be followed by hemiplegia, or there may be no 
paralysis, but the mental development is interfered with. Such children 
often suffer from convulsions and finally become epileptics. 

Most of the cases of hemiplegic and paraplegic idiocy come under this 
head, and also many of those who suffer from general or partial athetosis. 
In these cases the limbs are perfectly quiet and relaxed when the patient is 
asleep or undisturbed, but when excited, or when any voluntary movements 
are attempted, there are a series of erratic and violent movements which are 



Accidental Idiocy 557 

not, or are only partially, controlled by the will, The legs are crossed and 
rigid, with the great toe dorso-flexed, the hands make a series of clumsy and 
irregular movements, with the wrists flexed and the fingers alternately flexed 
and extended. All degrees of mental imbecility are associated with athetosis. 
Athetosis also occurs in late hemiplegia. 

Congenital Idiocy xuith Athetosis. — William H. D., aged 4 years. Birth easy, has never 
been right, cannot sit up, or walk or talk. Is a well-nourished boy, head small (18-in. 
circumference), small development in front. He smiles when he sees a watch, understands 
when asked if he will have a drink. Lies quiet when undisturbed ; when moved, or when 
he tries to sit up or reach out his hand for anything, the movements begin. If he tries to 
pick up a coin, his hands and arms, legs, face are thrown into erratic and vigorous move- 
ment. He perhaps seizes the coin after several attempts, then it is flung out of his hand. 
Tries to speak and makes a puffing noise with his lips. He manages to get out ' ma,' ' ta,' 
'ye,' ' na,' &c. 

Traumatic Idiocy with Athetosis. — Miles G., ioyears. Birth difficult and instrumental. 
He has always held his limbs more or less stiff, this was more noticeable at 10 months of 
age than before. He cannot speak, but makes a grunt for ' yes ' and another different 
grunt which means ' no.' He understands something of what is said to him. The head 
is rather small, being somewhat flattened in the parietal regions and also narrow in 
front. He lies quite quiet and helpless in bed when left to himself; when disturbed, or 
when anyone goes near him, the movements begin. He arches his back, moves his head, 
makes grimaces, arms and hands are extended and flexed alternately, the wrists are flexed, 
there is spasmodic opening and closing of the fingers. The legs are crossed, the knee 
extended, the foot points, the great toe is dorso-flexed. When left to himself the move- 
ments quiet down. He cannot feed himself, or, indeed, in anyway attend to his wants. 

4. Bull and Backward Children. — The name sufficiently indicates this 
class of case. It is often difficult to say whether a child is only behindhand 
in development or his mental powers are deficient. In most cases time will 
decide this. Backwardness is at times associated with epileptiform fits, or 
other nervous troubles. Children of this class are a constant source of 
anxiety to their parents ; they go to school and always gravitate to the 
bottom of their class, being perhaps left behind by their younger brothers 
or children many years younger than themselves ; out of school they are 
bullied or teased by their playmates. It is often difficult to know what to 
do with them ; certainly neither a large school nor home life is suitable. 
They are best educated in a small school where backward boys are received 
and special attention paid to them. 

Many of these dullards will be found attending ordinary board schools, 
who after perhaps four or five years' attendance cannot add up two or three 
simple figures, or have to do so with the aid of their fingers or by dots made 
on paper. Sometimes there is what appears to be ' word blindness.' Thus 
a boy of eleven years, after having been five years at a Board school, could 
not read the simplest words correctly or write from dictation, but could add 
up figures quickly and correctly. He was clever with tools and of normal 
intelligence in every way except in learning reading and writing from dicta- 
tion. He could write a good hand from a copy. Backward children very 
frequently articulate badly, drop letters out of words, and use the easy letters, 
as p, b, d, &c, in place of the difficult ones. 

5. Idiocy due to Congenital Syphilis. — The statistics of asylums 
for idiots and imbeciles do not support the view that mental feebleness 
in children is due to any large extent to the results of inherited syphilis. 



55 tf Diseases of the Nervous System 

Dr. ('.. E. Shuttleworth ' records that out of 1,000 inmates at the Royal Albert 
Asylum for Idiots at Lancaster, in only ten rases was there any reason for 
suspecting syphilis, and in four only was the evidence satisfactory. We 

have already referred (pp. 454 and 482; to certain lesions, such as meningo- 
encephalitis and endarteritis, which give rise to brain softening and complete 
dementia ; but such cases are rare, and are usually fatal at a comparatively 
early period of life. The commoner form of syphilitic idiocy does not 
manifest itself till the child is some six or seven years old, or even later, and 
takes the form of a sort of dementia or nervous breakdown. The child 
has perhaps learnt to read and shown a fair amount of intelligence ; it then 
gradually becomes more and more stupid and dull, and finally becomes 
completely demented. There is usually a general paresis, so that the child 
cannot stand or sit up and has to keep his bed. This paresis comes on 
gradually in some cases, being associated with choreiform movements or 
epileptic seizures. The dementia in time becomes well marked, so that the 
child does not recognise his friends or understand anything said to him. 
The course of the disease is chronic, lasting for years, so that such patients 
often finally drift into the workhouse infirmaries. They rarely are seen in 
Idiot Asylums, as the paresis mostly comes on before the dementia. In some 
few cases we have seen children suffering from syphilis, who have become 
first dull and backward and later mischievous and half insane. In all such 
cases it is important to inquire for a history of syphilis, and to carefully 
examine the patient for evidence of this. Keratitis, scarring about the mouth, 
pegged teeth, disseminated choroiditis, &c, should be looked for. 

The changes found in the brain in these cases consist in a chronic end- 
arteritis and meningitis ; there is also thickening of the skull. 

Morbid A?iatomy. — Space will not allow of any description of the malfor- 
mations or lesions found in the brains of idiots or imbeciles. The varieties 
of malformation found are very numerous ; the brain may be abnormally 
small, the frontal or posterior lobes may be ill-developed, the two halves 
may not correspond, or the corpus callosum or commissures may be absent. 
In another class of case there may be chronic meningitis, pachymeningitis, 
or atrophy of the cortical centres. 

Treatment. — The physical and intellectual training of children of deficient 
mental power is best undertaken in some institution specially equipped for 
the purpose. Home is certainly not the best place for their education. In 
the large majority of instances they are either over-indulged or neglected by 
their parents, brothers, and sisters. The association of the cleverer brothers 
and sisters often produces a feeling of discouragement in the feeble-minded, 
and of hopelessness at the wide gap which separates them from others. The 
discipline of a well-managed school or institution is of the greatest advantage 
in teaching them self-control and self-respect, and the companionship of 
those who are more or less on an equality as far as intelligence is concerned 
is calculated to bring out their mental powers far more than is the association 
with those that are greatly their superiors. If a school education is necessary 
for the children of parents who are in comfortable circumstances, how much 

1 ' The Influence of Hereditary Syphilis in the Production of Idiocy or Dementia,' by 
J. S. Bury, M.D. — Brain, Part XXI. ' Idiocy and Imbecility due to Inherited Syphilis,' 
by G. E. Shuttleworth, B.A., M.D. — American Journal of Insanity, January 1888. 



Treatment of Mental Defects 559 

more is the shelter of an institution necessary for the feeble-minded among 
the lower classes ! The Board school refuses to be troubled with them ; they 
are teased and worried by their companions in the streets, while they are 
alternately over-indulged or scolded and neglected by their parents ; their 
life is miserable, and they grow up useless members of society and an 
encumbrance to their friends. Unfortunately the several excellent public 
institutions for the training and education of feeble-minded children in this 
country are too few in number for the work they have to do. Moreover, they 
labour under an unfortunate name, viz. 'Asylums for Idiots and Imbeciles,' 
when as a matter of fact they are not asylums for providing a home for 
useless members of society, but schools where weak-minded children are 
trained to take their part — though a very minor part — in the battle of life. 
These circumstances undoubtedly operate in the minds of parents, who 
might otherwise be not averse from sending their children to training schools, 
but who shrink from branding them as idiots or imbeciles. 

It is needless to say that children who are idiots or weak-minded need a 
plentiful supply of good food ; and that especial care must be taken to keep 
their apartments warm as well as ventilated, as they are exceedingly prone to 
suffer from pneumonia and tuberculosis. 

During the last few years special classes for dull and defective children 
have been provided by the School Boards of several of our large cities, as, for 
instance, in London and Bradford. It was found that such children made 
no progress in the ordinary classes or in the infant school, and required 
special training. In these classes musical drill, object lessons and drawing, 
naturally take a prominent place. Similar classes are being established in 
other cities at the present time. 

Cra?iiectomy. — Recently an operation under this name has been intro- 
duced, based on the supposition that in certain cases of mental deficiency 
the defect is due to premature closure of the cranial sutures and consequent 
arrest of growth of the brain. The operation consists in the removal of a 
strip of bone along one or both sides of the middle line of the skull, or in 
some cases over the motor area, thus allowing the brain room to grow. The 
operation is a somewhat serious one, and we do not think it has been followed 
by any permanent improvement. We have tried it in two cases of hopeless 
deficiency, the result of infantile meningeal haemorrhage, but in such condi- 
tions, as might have been expected, no marked improvement followed. It is 
clear that a good result can only be looked for when the brain is small and 
undeveloped, but not actually anywhere destroyed. Both our cases recovered, 
but in one there was for a time marked hyperpyrexia, apparently a direct 
result of the operation from disturbance of the brain, and not due to septic 
causes ; one of Mr. Horsley's cases died of a similar condition. The brain 
from one of our cases, which died some months after the operation from 
causes unconnected with it, is figured at page 509. 

6. Cretinoid Idiocy. Sporadic Cretinism. Congenital Myxcedema. — 
Cretinism is endemic in mountainous districts of Europe, especially in the 
Swiss Alps ; it is comparatively rare in this country, though examples may 
be met with in the hilly parts of Derbyshire, Yorkshire, and Somersetshire. 
Examples of this form of cretinism may be met with in asylums. Dr. 
•Shuttleworth records a remarkable case, who died at the age of twenty years 



560 



Diseases of the Nervous System 



in the Royal Albert Asylum at Lancaster. In such cases there is usually, 
but not universally, an enlarged thyroid gland, and goitre usually prevails 
in the same localities. 

The form of cretinism of most interest is the form which was described 
by Hilton Fagge under the name of 'sporadic cretinism.' It is, however, 
by no means unlikely that these cases are in reality more related to myx- 
cedema than to the form of cretinism so well known in the mountainous 
districts of Europe. They differ from the latter in that the thyroid is absent, 
and the skin and subcutaneous tissues are thick and myxedematous. Ex- 
amples of this form have 
been met with in all parts of 
this country, Europe, and 
America. Endemic cretinism 
is apparently unknown in 
America, while sporadic cases 
are not uncommon in Xew 
York and other American 
cities (Koplik). 

In many of the cases 
which have come under ob- 
servation there has been a 
history of the child being 
born of healthy parents, 
and of being well till some 
illness occurred, such as 
measles or typhoid fever, 
after which the child ceased 
to grow and gradually de- 
veloped the peculiar physio- 
gnomy of cretinism. In one 
of our own cases the boy 
was said to have been well 
till an attack of enteric fever 
at seven years of age ; in a 
case recorded by Fletcher 
Beach the disease dated from 
whooping cough at twenty 
months. But it must not be 
forgotten that the ignorant 
classes are very unobservant, and are apt to attribute idiocy or backwardness 
to some acute disease, rather than acknowledge it has existed from birth. 
In other cases the history points to the child having been affected from 
birth. There is reason also to believe that cretinoid changes are in opera- 
tion during pregnancy, and that some of the cases in which softening of the 
bones is supposed to be due to infantile osteo-malacia are in reality fcetal 
cretinism. There can be little doubt that cretinism is overlooked during the 
first months or even years of life, inasmuch as the physiognomy and sym- 
ptoms are not as well marked as they are later on. Such infants may never 
be brought to a doctor for advi.ee, or the parents may seek advice only on 




A Cretin four years of age. 
not stand without help. 



She could 



Cretinoid Idiocy 



5 6i 



account of constipation. In many of these cases all the evidence of cretinism 
consists in a dull and heavy look, backwardness in intelligence, and obstinate 
constipation. In more marked cases in infants, the tongue is large, the neck 
short and thick, the abdomen excessively rounded, the skin generally thick 
and wrinkled ; the infant is certain to be dull and stupid, and there is always 
constipation, there being no power to expel the faeces. No thyroid gland can 
be felt. 

When the child is older the appearances are far more striking and the 
physiognomy is very peculiar and characteristic. They are dwarfs, being 
stunted in growth : one of our 
own cases, that of a boy aged 
12 years, measured 34 inches high 
and weighed 28 pounds. In two 
cases of Hilton Fagge's, one, aged 
16^ years, was only 32 inches high ; 
another, 20 years old, was only 
28 inches in height. Their heads 
are large and broad, often flattened 
at the vertex ; the face is broad, 
the eyes wide apart, the nose 
flattened, and the lips are large and 
pouting. The tongue is strikingly 
large and thick, and sometimes 
hangs from the mouth ; the belly 
is tumid, the umbilicus protruding 
and low down in its position, the 
lower limbs are disproportionately 
short as compared with the body, 
the gait is awkward and waddling. 
The skin is coarse and thick, and 
of a sallow colour ; in some the 
subcutaneous tissues are thick and 
myxcedematous. Usually no thy- 
roid is present, or, if present, is 
very small, but in almost all cases 
described peculiar fatty tumours 
are present in the posterior tri- 
angles of the neck behind the 
sterno-mastoid muscles and imme- 
diately above the clavicles. These 

tumours are soft, movable, and lobulated ; they send processes behind the 
sterno-mastoid muscles and also beneath the clavicles. 

The degree of intelligence in these cases differs : mostly they are childish 
in their ways rather than imbecile. They are late in learning to sit up and 
walk, and late also in talking ; in the worst cases they are completely 
imbecile. They are mostly good-humoured and easily controlled. In one of 
our cases the boy was employed by his father, who was a butcher, to stand 
outside the shop on Saturday nights and shout out the price of meat. His 
peculiar appearance and quaint remarks always attracted customers. Cretins 

O O 




Fig. 118 



Cretin. Walter P., aged 4^ years, 
height 31 inches, weight 28 lbs. 



562 



Diseases of the Nervous System 



are apt to suffer from tuberculosis both of the bones and internal organs, and 
also from rickets. 

Fig. 118 represents a boy of 4 \ years, the subject of cretinism. He was never right 
from his birth ; his brothers and sisters were healthy. He has never talked, only utters 
grunting sounds. Hardly understands anything said to him, but laughs if amused. The 
skin is coarse and the subcutaneous tissues thick. He has large lips and tongue ; his hands 
and feet are disproportionately large. No thyroid gland can be felt ; the supraclavicular 




Fig. 119. — Walter P., aged 7 years. 



pads are present. He has caries of the ethmoid bone and a chronic discharge of pus from 
the left eye. He remained in hospital ten months, during which time his left eyeball was 
excised on account of suppuration ; he was treated for awhile with subcutaneous injections 
of a glycerine extract of sheep's thyroid, but they had to be omitted from time to time on 
account of subcutaneous abscesses. He was discharged improved. He was lost sight of 
for two )^ears, when he came under the care of Mr. W. Barker Bale in the Stockport 
Workhouse (see fig. 119) ; he was treated with thyroid and greatly improved (see fig. 120). 
We are indebted to Mr. Bale for the photographs. 



Cretinoid Idiocy 



563 



All degrees of severity may be met with in congenital myxcedema, and 
the slighter cases are very apt to be overlooked. In the mild cases there 
maybe little else to note except that the child or the young adult is a dwarf; 
probably also there is mental dulness and backwardness. In exceptional 
cases sporadic cretinism is associated with congenital deaf-mutism. In one 
family we know, the oldest child, a girl, is completely deaf, though there was 




Fig. 120. — Walter P., aged 8 years, after nine months' treatment with 
thyroid extract. 



apparently some hearing power during her first two or three years ; she 
suffers from an enlarged and cystic thyroid ; the second, a boy, is partially 
deaf; the third, also a boy, is a deaf-mute, and suffered from sporadic 
cretinism ; he has greatly improved with thyroid extract. 

Treatment. — While thyroid extract is of the greatest value in all forms 
of congenital myxcedema or ' sporadic cretinism,' there is good evidence to 
show that the earlier in life it is taken the better will be the result of its action. 

002 



564 



Diseases of the Nervous System 



We usually begin in young patients with \\ gr. of the dried sheep's thyroid 
glands given in the form of tabloids daily, increasing to two or three daily 
according to circumstances. It is necessary to watch the patient carefully, 
inasmuch as the thyroid extract is a powerful remedy, and individual 
susceptibility to its influence differs considerably. It is important to 
watch the pulse and temperature ; if there is an evening rise of two or 
three degrees, it will be well to omit the drug for a while. Cretins for the 
most part have a subnormal temperature, and an evening rise of over ioo° 
is likely to be due to ' thyroidisnv With this evening fever there is usually 





Fig. 121. — E. A. W., aged 2 years, 
height 24I in., weight 16 lb. 2 oz. 



Fig. 122. — E. A. W., aged 4^ years, 
height 33 in., weight 30*5 lb. 



irritability and shortness ot temper ; this we have noticed again and again 
in hospital patients. There may be vomiting-Jaundice, diarrhoea, and marked 
depression of the heart's action. Of these symptoms vomiting, irritability, and 
fever are the commonest signs of early thyroidism, and should always be taken 
as danger signals and the drug omitted. In a later stage there is pallor, and 
faintness on exertion ; we have seen this in one case so marked that it seemed 
likely a fatal result might ensue. We have seen a continued depression and 
tendency to fainting lasting for many weeks. With the continued adminis- 
tration of thyroid extract and rapid growth which may take place, the child 



Cretinoid Idiocy 565 

is apt to become thin and limp, with a tendency to knock-knees and lateral 
spinal curvature. 

Under the influence of moderate doses of thyroid extract — that is, doses so 
regulated as not to produce an}" symptoms of thyroidism — the improve- 
ment in the patient is most striking. The facial expression entirely changes, 
the dull heavy look disappears and is succeeded by a bright and pleasing 
expression, the lips are no longer thick, the tongue diminishes in size. The 
skin becomes soft, the abdomen less tumid, and the child begins to shoot up. 
The change is generally observable within a few weeks of the commence- 
ment of treatment. Loss of weight occurs at first. With the omission of 
the thyroid treatment there is almost a certainty of a relapse, and we have 
seen relapses frequently among out-patients, though perhaps the patient has 
not gone back quite to its former condition. It is necessary to continue the 
treatment, though the amount of the drug may be diminished to, say, 5 grs. a 
week, for years. It can confidently be predicted in a give:: case, if the 
symptoms of cretinism are present, that improvement will take place under 
the thyroid treatment, but how much improvement time only will show. The 
physical improvement in many cases outruns the mental improvement, 
the experience of most being that average mental power is only excep- 
tionally attained by cretins under treatment. But more experience is required. 
Unfortunately, so many of our patients among the poorer classes are lost 
sjght of and do not persevere with treatment. 



566 Diseases of the Nervous System 



CHAPTER XXVI 

DISEASES OF THE NERVOUS SYSTEM — {continued) 

Spina Bifida 

Spina bifida is a congenital malformation in which there is non-union of 
the laminae of one or more vertebrae, together with a protrusion of a sac 
composed of the spinal cord or its membranes through this opening. The 
deformity maybe considered as due to a failure of the mesoblast to interpose 
itself between the spinal and cutaneous epiblast, with or without lack of 
coalescence of the medullary folds themselves. The protrusion may occur 
at any part of the spine, and may extend throughout nearly its whole length ; 
usually only three or four vertebras are involved, and the lumbar or sacral 
region is the part most commonly affected. 1 Very rarely the bodies of the 
vertebrae are divided, and the hernia projects forwards or laterally. In some 
instances there is no protrusion, though the laminae have not united (' spina 
bifida occulta'), and occasionally there is more than one hernia. 

Three kinds of spina bifida are recognised : 

i. Protrusion of the spinal membranes only : 'spinal meningocele.' 

2. Protrusion of the membranes together with the spinal cord and nerves : 
' meningo-myelocele.' 

3. Protrusion of the membranes and cord, the central canal of the latter 
being dilated to form the sac : ' syringo-myelocele.' 

To these should be added the cases where the medullary plates fail to 
coalesce — ' myelocele ' — and the central canal opens upon the surface, a con- 
dition incompatible with life for more than a few days. Also a" meningo- 
cele may co-exist with a 'syringo-myelocele,' constituting a ' syringo-menin- 
gocele ;' and finally there is ' spina bifida occulta.' 2 

The second kind of deformity is much the most common, forming 63 per 
cent, of all the cases. 

In the first form the swelling is usually small, and may protrude merely 
between two almost normal spines ; the cavity of the sac is the subarachnoid 
space, the swelling is often covered with well-formed skin, and paralytic 
complications are often absent. 

The vertebral laminae vary much in development ; the gap may be very 
wide and the laminae much stunted, or they may form prominent everted 
borders to the orifice. 

1 Eighty-nine cases out of 125 collected by the Clinical Society were lumbar or sacral. 

2 Vide Bland Sutton, Lancet, February 25, 1888. 



Spina Bifida 567 

The central canal of the cord is often dilated in the first two forms as 
well as in the third, and the position of the cord in the sac varies ; it maybe 
slung up in the sac by a sort of mesentery, but in any case is very imper- 
fectly developed, and is occasionally transfixed by a bony process crossing 
the canal. 

Syringo-myelocele is very rare ; the sac is composed of spinal membranes 
plus the cord, and, the cavity being the dilated central canal, the nerves are 
embedded in the sac wall and do not cross the cavity. 1 

The fluid in a spina bifida consists of 98-9 per cent, of water with soluble 
salts and a trace of sugar, or at least some copper-reducing substance ; also 
small quantities of globulin ; it is, in fact, cerebro-spinal fluid. Where, how- 
ever, the cavity of the sac is continuous with the subdural space, no sugar 
will be found.' 2 

In meningo-myelocele, the common form, the sac is formed of dura 
mater lined by arachnoid (both 'layers'), hence the cavity is the subarach- 
noid space. The spinal cord traverses the sac and blends with its roof ; from 
the flattened thinned-out cord the spinal nerves arise and pass across the 
sac to their respective foramina. The surface of the sac may be covered 
entirely with skin, or may be thin and transparent, only consisting at its 
upper part of the membranes, or membranes covered with an imperfect 
epidermic layer, while at the sides the skin is usually better formed. Some- 
times a dimple or longitudinal furrow in the middle line marks the attach- 
ment of the cord and shows its presence in the sac, an important point in 
the question of treatment. Sometimes the sac is loculated. 

The tumour resulting from spina bifida is median in position, usually 
sessile, fluctuant, and translucent in varying degree, according to the amount 
of healthy skin covering it. Lateral meningocele has been, however, met 
with. The contents can be partially reduced into the spinal canal, 
unless the communication has been shut off (false spina bifida). The 
surface not uncommonly is ulcerated, and is sometimes marked by 
nsevoid tissue, as in the case of meningoceles. The swelling becomes tense 
on the child crying, and there is often some associated deformity ; hydro- 
cephalus, meningocele, talipes, harelip, a peculiar webbed condition of the 
thighs (' siren '), or other deformity may coexist, and the subjects of spina 
bifida are often marasmic and soon die ; in other cases, however, they are 
fat and hearty. We have seen them too fat, the subject of a sort of diffuse 
lipomatous condition such as is sometimes seen in cases of talipes. On the 
whole, paraplegia, talipes, and hydrocephalus are the three commonest com- 
plications. ' Trophic ' ulcers are sometimes seen on the feet. 

Diagnosis. — The diagnosis of spina bifida can only be doubtful where 
there is a complete skin-covering to the tumour. In such cases congenital 
sacral, or other tumours — hygroma, teratoma, or lipoma — may be mistaken 
for spina bifida, and the possibility of the communication with the spinal cord 
having been shut off must also be borne in mind. The presence of solid 
masses in a median tumour and the absence of general fluctuation would 

1 A case of this sort has been recorded by Morton in the Bristol Med. CJiir. Jour., 
March 1892. 

2 A case of this nature was reported by Pearce Gould in the Clin. Soc. Trans. 1882. 
Injection oured the patient. 



568 Diseases of the Nervous System 

point to a teratoma or lipoma, while a hygroma is more spongy, usually 
flatter, and often not exactly median. The presence of mevus-stains may 
raise the question of whether the whole swelling is not nasvoid. The fixity 
of the tumour to the spine, its reducibility, the possibility of feeling the edges 
of the opening in the laminae, and the coexistence of other deformities may 
throw light upon a doubtful case. In some instances puncture with a fine 
needle and examination of the fluid drawn off may be required ; a highly 
albuminous fluid would be inconsistent with spina bifida. Non-congenital 
tumours cannot, of course, be confounded with spina bifida. The per- 
sistence of communication with the meningeal cavities can be determined 
by variations in the size of the swelling. The term ; false spina bifida,' 
usually limited to cases where the sac no longer communicates with the sub- 
arachnoid space, is sometimes applied to any median congenital tumour 
along the spine. 

Prognosis. — Nearly all cases of spina bifida left to themselves die, 
mostly from meningitis after rupture of the sac, or from marasmus ; some, 
however, recover completely, the sac shrinking up and forming a mere 
puckered cicatrix. Occasionally spontaneous cure takes place in utero, 
and even rupture is not universally fatal. Cure of the spina bifida, it must 
be remembered, does not imply cure of paralysis or other complications. 

Treatme?it. — Though simple repeated tappings, pressure, ligature, and 
excision have all occasionally proved successful in the treatment of spina 
bifida, the Clinical Society's report shows that the safest and most gene- 
rally applicable plan is that of injection, and probably Morton's fluid x is 
the best for this purpose. Either ligature or excision is almost necessarily 
fatal where the case is one of meningo-myelocele, and as this is the most 
common form, 2 and it is impossible to be sure in any given case that a 
simple meningocele is present, the plan is only occasionally applicable. 3 

Treatment by injection is managed as follows : The child should be 
held back downwards, and a fairly fine injecting syringe should be charged 
with Morton's fluid ; the needle is then passed in obliquely through the skin 
and from fifteen minims to a drachm of the fluid injected. Care must be taken 
that the puncture is made through skin and not through thin membrane, 
and that it is well away from the middle line, both to diminish the risk of 
subsequent leakage and to avoid injury to the cord or nerves. After the 
injection, the child must be kept upon its back, the puncture sealed with 
collodion, the tumour packed well round with absorbent wool, and a flannel 
bandage applied. It is perhaps better to withdraw some fluid before injecting, 
and the child must be kept entirely in the supine position, to prevent the 
fluid from passing into the spinal canal. If the tumour does not shrink and 
no ill effects follow, the injection should be repeated at intervals of a fort- 
night. Occasionally the tumour does not begin to shrink for a month or two 
after an injection, as in a case related to us by Dr. Wallace, of Longsight. 

1 Iodine gr. x, iodide of potassium gr. xxx, glycerine Ji. The amount of iodine may 
be increased up to gr. xxx. 

2 Prescott Hewett found only" one case out of twenty in which there was no nerve 
element in the sac. 

3 Mr. Mayo Robson, of Leeds, and others, have had some successful cases, but the facts 
remain as above stated. 



Spina Bifida 



569 



Injection may fail to produce any effect, may result in immediate death, 
may be followed by leakage or hydrocephalus ; a single injection may 
cure, or several may be required. This plan should be employed in all 
cases unless the child is obviously marasmic or dying from rupture of the 
sac, or unless the tumour is quiescent and giving rise to no trouble ; or, of 
course, if it is shrinking spontaneously, no treatment should be adopted. 

Sometimes a spina bifida is ruptured at birth, or sloughs shortly after- 
wards from pressure ; nothing can be done for such a case except to dust it 
over with iodoform and protect it carefully from pressure and contamination 
with the child's discharges. We have not seen a case recover when the sac 

has been ruptured in this way, though 
^j recovery does occasionally occur 

Maylard). Superficial ulceration is 
less serious and should be managed 
in the same way. Even if the spina 
bifida is cured by injection, it is not 





Fig. 123. — A case of cured Spina Bifida (by 
injection) with co-existing Talipes. 



Fig. 124. — Shows a section through a Spina 
Bifida cured by injection. A small cavity 
still remains. The child died some time after 
of scarlet fever. 

rare for hydrocephalus to appear 
later ; hence the mortality, direct or 
indirect, among these cases is very 
high. 

As already mentioned, in certain 
cases the sac becomes shut off from 
the general cavity of the membranes and the cyst remains without com- 
munication with any important structures : such result can only occur in 
meningoceles : the tumour then usually requires no treatment ; it may, how- 
ever, be tapped or injected and excised with probably impunity. These cases 
and sacral spina bifida are the ones most likely to be successfully treated by 
excision. 

In connection with spina bifida must be mentioned the so-called sacral 
or coccygeal dimple described by Lawson Tait and others. This is a 
small dimple or depression in the skin over the lower part of the sacrum or 
upper part of the coccyx ; it can often be obliterated by traction upon the 
skin. It probably results from imperfect obliteration of the dorsal furrow, 



5/0 



Diseases oj the Nervous System 



a sort of incomplete spina bifida. Fig. 125 shows a more marked condition 
of the same thing, which was associated with talipes. It has been pointed 
out by Dr. Dunlop, of Jersey, 1 that the dimple may be associated with bending 

back of the coccyx. Another view of the ori- 
gin of this little depression, which is quite com- 
monly to be found, is that it represents the ' pos- 
terior umbilicus,' or 'blastopore.' It has been 
supposed to be the remains of the neurenteric 
canal. Congenital sacral fistula? are a more 
marked condition of the same thing : they may 
cause trouble by retention of sebaceous secretion 
and require removal ; a tuft of hair or ' caudal 
appendage ' has been found in the neighbour- 
hood of these fistula? (Terrillon, Gueniot, &c). 
The case here figured (fig. 125) appears to bean 
intermediate condition between the ordinary 
spina bifida and the rare condition described as 
' spina bifida occulta,' in which the laminae of 
one or more vertebras are deficient, but there is 
no hernial protrusion. In ' spina bifida occulta : 
the site of the deficiency is marked by a local 
overgrowth of hair, and there appears to be 
usually a coexisting (resulting) tendency to the 
development of perforating ulcer of the foot and 
pes varus. We have noticed an overgrowth of 
hair and a formation of trophic ulcers in cases 
of spina bifida cured by injection ; both the 
hypertrichosis and the ulcer developed only 
when the tumour was more or less completely 
shrunken. In such cases endarteritis and neu- 
ritis of the affected foot have been found, with 
great hypertrophy of the muscular coat of the 
arteries. In cases of spina bifida, both manifest and ' occult,' paralyses and 
contractures of the lower extremities have been relieved by operation, and 
the removal of bands and fibrous or fatty masses pressing on the cord or 
nerves. 




Fig. 125.— Slight sacral Spina Bifida 
which has undergone spontaneous 
cure. The girl had also Talipes, 
and was mentally dull. There was 
an ulcer on the dorsum of the foot. 



S^enin^ocsle 

Malformations corresponding to spina bifida are not rarely met with in the 
head. The most common form is a hernia of the meninges forming a 
meningocele, the cavity of which is the subarachnoid space. In other 
instances the protrusion contains brain substance as well — encephalocele, 
or hydrencephalocele, or meningo-encephalocele ; the last is, according to 
Treves, the commonest, and pure meningocele the rarest form. 

These hernias are most common in the occipital region, the protrusion 
taking place through a median opening corresponding to the space between 
the centres of ossification of the supra-occipital bone. In other instances it 

1 Lancet, May 6, 1882. 



Meningocele 



57 



occurs at the root of the nose, through the suture between the frontal and nasal 
bones, or at one or other angle of the orbit, or at other parts, 1 the pharynx, 
&c. The general characters of these cysts need no further description 
here ; they are precisely those of a spina bifida, except that the skin over a 
meningocele is more often normal. The fluid is often partially or wholly 
reducible, and its reduction may give rise to pressure symptoms ; the swell- 
ing becomes more tense when the child cries, and is more or less trans- 
lucent according to its contents, whether fluid or cerebral. The course of 
these cases is often the same as that of a spina bifida : the swelling grows 
and ruptures, and the child dies ; sometimes, however, the cyst shrinks after, 
or without, rupturing. 

Diagnosis. — The diagnosis is in most cases easy : the swelling is in the 
position of a weak spot in the skull ; it is congenital. The opening in the 
skull can usually be felt, and the other characters mentioned suffice to dis- 
tinguish it. Sometimes, however, especially when small, it is difficult or im- 
possible to distinguish meningoceles from dermoid cysts, or cysts connected 
with naevi, especially as nsevoid patches are common on the surface ot 





126. — Occipital Meningocele 



Fig. 127. — Frontal Meningocele. Spontaneous cure, with 
resulting deformity of the nose. (Dr. Moritz's case.) 



meningoceles. Dermoid cysts sometimes cause perforation of the skull 
beneath them, and hence are very difficult in such cases to diagnose with 
certainty : they are, however, usually more mobile and less affected by pres- 
sure than meningoceles. The deformity is often accompanied by idiocy, 
paralysis, or spastic contractures, and other malformations. In some cases 
the protrusion may attain enormous bulk, the greater part of the cranial con- 
tents being lodged outside the skull. Most museums contain specimens ot 
this sort, which have, however, no practical surgical bearing. 

Treatment. — Unless the tumour is enlarging, no treatment except pro- 
tection is wise ; should anything be desirable, repeated tappings or injection, 
as in the case of spina bifida, is the best course for meningoceles. Attempts 
have been made to excise the tumours, with sufficient success to encourage 
further trials, in selected cases. We have successfully excised an occipital 
meningocele in which the tumour did not communicate with the membranes ; 

1 The late Dr. Carrington has recorded a case of interparietal hydrencephalocele [Clin. 
w c. Trans. 1881) ; and the protrusion sometimes takes place through the foramen mag- 
nv.m 1 Holmes. St. George s Hospital Reports, 18661 : in this case the cyst was loculated. 



5/2 Diseases of the Nervous System 

but in the operation the membranes, or at least another sac, were opened 
No ill result followed. If excision is attempted the skin should be as f; 
possible dissected back from the membranes, and the latter either tucked 
into the skull or removed and their edges stitched together. \Yc have also 
excised an occipital meningo-encephalocele in which a piece of the cere 
bellum of the size of a walnut was removed ; the child recovered, though 
it developed hydrocephalus after the operation. 1 But we have had tv. 
three fatal cases of excision of meningoceles since. 

Schatz reports favourably of the treatment of occipital meningoceles by 
puncture and pressure, and records a cure in three cases by constriction of 
the pedicle with clamps. (Berli?i. Klin. Woch. 1885, No. 28, p. 371. 

Much deformity is sometimes produced by the presence and shrinkage of 
a meningocele (see fig. 127, kindly given us by our friend Dr. Moritz). 

Occasionally meningoceles protrude through the roof of the pharynx or 
nasal cavities : in such cases mistakes as to the nature of the swelling have 
led to speedily fatal results after operation.- 

Spinal Meningitis 

Spinal meningitis mostly occurs in its acute form in association with 
cerebral meningitis, and in its chronic form in connection with spinal caries 
Acute cerebro-spinal meningitis has already been referred to (p. 480), and 
the symptoms of spinal meningitis, when superadded to those of cerebi 
meningitis, discussed. The dissociation of the symptoms of each is not 
easy, as cerebral disease gives rise to symptoms closely resembling those 
given by a spinal lesion. Thus, basal meningitis, especially when it occurs 
low down around the pons, medulla, and cerebellum, will produce tetanoid 
rigidity with spasms of the muscles of the back and neck. A tumour of the 
middle lobe of the cerebellum may produce acute pain referred to the spine 
and spasm of the erector spinas (see case, p. 495). On the other hand, spinal 
meningitis, either tubercular, simple, or purulent, may be ioxm&ftost mortem, 
having given no definite symptoms during life, certainly not those usually 
associated with spinal meningitis. 

The most characteristic symptoms of spinal meningitis are shooting 
pains down the limbs and round the body, with hyperesthesia of the skin, 
rigors, quickened pulse, and fever. There are rigidity about the limbs, 
retraction of the head, and tenderness about the spine. The diagnosis is 
often difficult : hysteria, tetany, and the cramps associated with acute 
intestinal catarrh, as well as cerebral meningitis, may be mistaken for it. 
Synovitis of the vertebral joints may resemble meningitis of the cord. If 
the spinal meningitis pass into the chronic stage, paresis of the upper and 
lower extremities may come on. 

Spinal meningitis is necessarily a disease which tends to a fatal termina- 
tion, but not so certainly as cerebral meningitis : certainly, cases diagnosed 

1 Mr. Jessop, of Leeds, also records a successful case of excision, but there was no 
distinct communication with the interior of the skull ; hence it has little bearing on the 
general question — Brit. Med. Jour. December 30, 1882. 

- For tables as to the frequency of different varieties, &c. vide Treves' Manual a 
Surgery, vol. ii. 



Spinal Meni7igitis~Paraplegia 573 

as spinal meningitis recover. Cases such as the following are not altogether 
uncommon : 

A girl aged 13 years complained six days before admission of pain in the back ; her 
head was drawn back, she could not sleep for the pain. On admission she was evidently 
acutely ill ; she la}- on her side in bed, with her legs drawn up, and there was great retrac- 
tion of the head ; there was much pain along the spine, aggravated on movement ; pain 
shooting along the arms was complained of; the pulse was 108, the temperature varied 
from 98° to io2 r Fahr. She was given chloral hydrate, and an ice-bag was applied to the 
spine ; for five or six days she continued acutely ill, the temperature varying from 97° to 
102 : ; there were several rigors on succeeding days : the head was retracted, any forcible 
movement forward caused pain, there was exaggerated knee-jerk, and ankle-clonus was 
present. The symptoms gradually subsided about a week after admission, leaving her 
very weak and emaciated. In six weeks she was discharged well. 

Such cases may be open to the suspicion that the inflammatory lesion 
present was in the vertebral joints or spinal muscles rather than in the 
spinal canal ; but, on the other hand, none of the other joints or muscles 
were affected, and there is no reason why a spinal meningitis should not 
occur and get well again. A case in which laminectomy, incision, and drainage 
of the theca was done successfully is recorded by Rolleston and Allingham 
in the ' Lancet' of April 1, 1899. 

Treatment. — Rest in bed, in perfect quietness, is essential. Ice to the 
spine is probably the best local application that can be used. The pain 
must be relieved by small morphia injections, or opium may be given by the 
mouth. Instead of opium, bromides and chloral may be first tried. 



Paraplegia 

By far the commonest cause of paraplegia during childhood is compres- 
sion of the cord from caries of the bones of the vertebras ; in rare cases the 
cord is compressed by a tumour, growing from the sheath of the cord. Other 
forms of paraplegia occur which may be due to myelitis, following measles 
or other zymotic disease, an acute atrophic paralysis affecting both legs, and 
some other anomalous paralyses of uncertain origin. There is also the 
spastic paralysis of cerebral origin and hysterical paraplegia. 

Compression of the Cord from Spinal Caries.— It is important to bear 
in mind that the paraplegia which occurs in association with caries of the 
spine is less often due to direct pressure from the deformity produced by the 
falling together and bending of the vertebrae than to the inflammatory pro- 
ducts which are thrown out around the cord. We may therefore have a 
paraplegia without the slightest external deformity of the spine, and, more- 
over, a perfect recover}- may issue in a given case by absorption of the in- 
flammatory products — a result that could hardly be expected if the compression 
was due to the direct pressure of a bent spine. The inflammatory process 
which commences in the body of a vertebra is apt to spread, so that lymph or 
curd\- pus is effused outside the dura mater, between the latter and the bone, 
or inside the dura mater, and the cord is compressed, or the cord may also 
be affected by the inflammatory process. Pressure on, and inflammatory 
changes in the cord itself may take place at any part of the cord — cervical, 
dorsal, or lumbar region. Pressure is also exceeding'lv likelv to affect 



574 Diseases of the Nervous System 

some of the nerves, the latter being surrounded and compressed by inflam- 
matory products as they pass through the dura mater and foramina. 

Syjuptoms. — Symptoms of compression of the cord or its branches may 
come on early or late in the disease. In the majority of cases the early sym- 
ptoms are those connected with deformity of the spine and perhaps irritation of 
the sensory nerves, and it is only late in the disease, when the deformity has 
been well marked for many months, that symptoms of pressure on the cord 
supervene. In the minority of cases it is the weakness and paresis of legs 
with exaggerated knee-jerk that suggest the onset of spinal caries. It is im- 
portant to bear in mind that a paraplegia may exist for many months 
without any deformity of the spinal column being present, the latter eventually 
supervening, and explaining the cause of the paraplegia which had remained 
in doubt. Gowers mentions the case of a patient who had complete para- 
plegia for six months ; an experienced surgeon who examined him was 
unable to detect the existence of spinal caries, and yet a few months later 
undoubted symptoms of bone disease appeared. 

The motor paresis usually comes on gradually : the child is weak upon 
its legs, quickly tiring, and supports itself whenever possible by the help of 
chairs or tables. When the dorsal cord is compressed the reflexes are 
exaggerated ; if the sole of the foot is tickled as the child lies in bed the foot 
is sharply withdrawn ; if the knee is bent by holding the ankle in the operators 
hand, a sharp tap on the patellar tendon gives rise to an exaggerated ' knee- 
jerk ; ' ankle-clonus can usually be readily obtained. Gradually a spastic 
paraplegia comes on : the child cannot walk, or later cannot stand, without 
help, and when lying down in bed the knees tend to draw up and the feet to 
be extended in consequence of the rigidity of the calf muscles. Usually 
there is no loss of sensation. The sphincters may be affected, and bladder 
troubles may ensue if the lumbar cord become involved by descending 
inflammation. Prior to the onset of motor or cord symptoms, there may be 
various shooting pains experienced along the intercostal nerves ; children 
with commencing caries of the spine will complain of ' belly-ache ' or refer 
the pain to the pit of the stomach or sternum. Thus pain referred to 
the umbilicus suggests that there is irritation of the tenth dorsal nerves 
(eighth dorsal vertebrae), or pain at the ensiform cartilage to the sixth and 
seventh nerves (fourth and fifth dorsal vertebras), or over the thorax to the 
upper dorsal nerves. There may be hyperesthesia or anaesthesia of the 
skin. 

When the cervical region of the cord suffers the symptoms are apt to be 
more marked than when the dorsal region is affected ; there may be pains 
shooting down the arms, shoulders, neck, and scalp, according to the position 
of the lesion ; hyperaesthesia and later anaesthesia of the skin. The sensation 
of pins-and-needles is often complained of. There is gradual loss of power 
in one or both arms, and wasting of the muscles. The shoulder muscles, 
serratus, flexors of the elbow and supinators are affected when the fifth and 
sixth nerves are involved ; the extensors of the wrist and fingers when the sixth 
and seventh ; and the extensors of the elbow, flexors of the wrist and fingers, 
and pronators, when the seventh and eighth are involved. A spastic para- 
plegia may come on, as in disease of the dorsal cord. 

When the lumbar enlargement is compressed, or its branches there is 



Parapleg ia — Myelitis 575 

paraplegia, the reflexes are not exaggerated, but are abolished, and no 
knee-jerk can be obtained— that is, if the pressure is severe enough to interfere 
with the functional activity of the grey matter of this region. The sphincters, 
both of the bladder and rectum, are likely to become paralysed if a compres- 
sion myelitis of the lumbar cord takes place. 

The course of the disease varies exceedingly, and depends upon the extent 
and chronicity of the inflammatory processes in the bones. Recovery from 
the paralysis may take place after the patient has been bed-ridden and help- 
less for many months and even years, and where recover}- was hardly thought 
to be possible. On the other hand, the progress may be from bad to worse, 
there being a gradually extending myelitis, so that the sphincters become 
paralysed and the patient suffers from incontinence of both urine and faeces. 
Sensation may become impaired, and the patient at last dies of exhaustion or 
the results of cystitis, or not infrequently of tuberculosis or lardaceous disease. 
For treatment see Disease of Spine. 

XWyelitis. — By far the commonest inflammatory lesion of the cord in 
children is that form which is localised in the grey matter of the anterior 
horns, which has received the misleading name of ' infantile paralysis.' 

An acute transverse myelitis occurs in children as well as in adults, but 
it is apparently less common. Disseminated or focal myelitis appears some- 
times to occur during some of the zymotic diseases, as typhoid fever, 
influenza, measles. Transverse myelitis is rare before the age of ten years ; 
it seems mostly to follow exposure to cold or accidents such as occur to 
schoolboys in the football field. In one of our cases, that of a boy of eight 
years of age, it followed paddling in the water. It is very probable that 
' catching cold ' or an ' accident ' is only the predisposing, the effective cause 
being a toxine formed by the action of micro-organisms. 

The symptoms are much the same as in adults ; the ultimate chance of 
recovery is, however, greater, as the cord seems to recover itself more readily 
in early life than in later years. There is usually a feeling of ' pins-and- 
needles ' in the feet, and sometimes rheumatoid pains followed by loss of mus- 
cular power. At first this may be slight, but after a few hours it becomes more 
marked, and within twenty-four or forty-eight hours it has reached its height. 
There is loss of sensation as well as motion, varying in extent according to 
the length of cord affected. There is also incontinence of urine and 
faeces ; if the lesion is above the lumbar enlargement, the sphincters con- 
tract normally, but the control exercised by the will is cut off. The com- 
monest part of the cord to be affected is the dorsal region ; often there is 
some feverishness. 

All degrees of motor and sensory paralysis may be present. In severe 
cases almost all power is lost and the legs fall about in a helpless wav, 
though usually some power of movement is retained in the toes. The 
reflexes may be completely absent. After a variable period, if the lesion is 
above the lumbar enlargement, the reflexes return and become excessive ; 
there is ankle-clonus, the knee-jerk is abnormally vigorous, and a condition 
of spastic paraplegia comes on. Sensation, if it has been absent, usually 
returns before recovery of motor power. 

The amount of recover} 7 which takes place is variable ; we have seen 
complete recovery eventually ensue in cases where, from the amount of 



576 Diseases of the Nervotts System 

motor and sensory paralysis present in the first instance, we had not thought 
it possible. Many months in bed are necessary to effect this ; the intense 
spastic paralysis gradually lessens and may eventually disappear. 

If the lumbar enlargement is affected, not only is there complete motor 
paralysis, but the muscles waste rapidly, the rectal sphincter is completely 
relaxed, and the urine dribbles away from paralysis of the sphincter of the 
bladder. 

If the cervical enlargement is affected, the arms are paralysed, the pupils 
may be dilated, and death is apt to ensue from interference with the nerve 
supply to the muscles of respiration. 

As an instance of a transverse myelitis occurring in the cervical region, 
followed by partial recovery, the following case may be related : 

Transverse Myelitis. — A healthy boy when a year old was exposed to cold by lying on 
the damp grass ; he woke crying during the following night, the parents thinking he had 
pain in the stomach ; he was not convulsed ; next morning both his arms and legs were 
limp and useless, he could not move them or sit up ; there was no facial paralysis. 
Recovery gradually took place, the arms recovering completely, the legs partially. When 
seen at two years of age, the arms had completely recovered, but both legs were weak, so 
that he could not bear his weight on them, but could crawl, dragging them after him ; 
sensation seemed impaired in the legs, there was ankle-clonus and exaggerated tendon 
reflex. The child was perfectly intelligent, and was well nourished, but the muscles of the 
leg were somewhat flabby. He has since been lost sight of. 

As instances of what were probably cases of subacute myelitis, one occur- 
ring after measles and another after what was said to be a ' cold,' we may 
mention the following cases : 

Myelitis following Measles. — Gertrude H., aged 4 years, was quite well till she con- 
tracted measles in August 1882 ; when convalescent it was noticed she could not stand by 
herself. She remained bedridden till admitted to the hospital in December. At this time 
she could not bear the weight of her body without help ; the knee-jerk was exaggerated, 
the front-tap contraction was present, there was no ankle-clonus. She slowly improved, 
and by February 1883 she could stand alone and walk with help, throwing her legs forward. 
She finally entirely recovered after some months. 

Myelitis. — George C., aged 13 years, was quite well till May 1882, when he caught a 
cold and had a feverish sore throat ; after this his legs became weaker, though he could 
always walk with help. He was admitted September 1882 ; his legs were both weak, but 
he could walk, swaying from side to side, bending both knees very much ; no loss of sensa- 
tion, muscles react normally to both continuous and faradic currents; knee-jerk exagge- 
rated, the slightest touch producing a jerk ; there was no evidence of any spinal disease. 
He remained much in the same condition till January 1883, when he went home. He 
finally completely recovered, after attending as an out-patient for some months. 

It is difficult to account for the symptoms in these two cases except on the 
supposition that they suffered from either compression or disseminated 
myelitis, which eventually got well. 

Dr. Thos. Barlow records a fatal case of disseminated myelitis 1 occurring 
during an attack of measles, which proved fatal on the eleventh day of the 
disease. He quotes two cases of children, aged two years and three years 
respectively, who suffered from paralysis apparently due to myelitis when 

1 ' On a case of early disseminated myelitis occurring during measles.'— Dr. Thos. 
Barlow, Proc. of the Royal Med. -Chir. Soc, vol. ii. p. 146. 



Landry's Paralysis S77 

convalescent from measles. We have seen several similar cases of paralysis 
apparently due to myelitis following measles ending in recovery. 

Landry's Paralysis, or acute ascending paralysis, is said to occur 
occasionally in children ; the following case in many respects resembled this 
form as it occurs in adults : 

Edward M'L., aged u years, had good health till January 1881, when he became ill 
from the effects of cold ; in a few days he became drowsy and had twitchings in the legs, 
which were said by a doctor to be due to St. Vitus's dance ; the movements ceased and 
left his legs paralysed ; eight days afterwards he lost the use of his arms, and he com- 
plained of pain in the head and was delirious for a week ; the weakness in the arms 
improved, but got worse again. When admitted in March 1881 his arms were weak, he 
moved his legs with difficulty, could just manage to raise them in bed ; no loss of sensa- 
tion ; the knee-jerk was almost absent ; no ankle-clonus. He gradually improved, so . 
that by April he was able to walk without difficulty, but swayed to and fro. He finally 
completely recovered. It is possible that this case was in reality one of peripheral neuritis 
rather than any spinal lesion. 

Treatment. — Perfect rest in bed is of the greatest importance in the 
inflammatory stage, all movements and excitation of the spinal cord being 
avoided as much as possible. The patient should lie on his side or his face 
in preference to his back, so that the spine should not be the most dependent 
part. Of local applications the spinal ice-bag is probably the best, though 
some prefer the application of moist heat with counter-irritation, such as 
mustard poultices, so as to redden the skin. Probably there are no medicines 
which can control or moderate the inflammatory lesion. Aconite, ergot, the 
bromides, have all been used with varying success. Both mercury and iodide 
of potassium have also been prescribed. 

Great care must be taken to prevent bedsores : perfect cleanliness must 
be observed, and pressure taken off any spot where the skin becomes red. 
The incontinence of urine and faeces is always a source of difficulty, as the 
urine and damp bed-linen fret the skin and give rise to sores. The best 
position for the patient is on his face, so that the urine as it dribbles away 
may be received into a bed-pan. Boric or iodoform cotton wool may be used 
to surround the genitals and absorb the discharges. If there is retention of 
urine, the catheter must be used. No good can be expected from the appli- 
cation of the faradic or galvanic current in the early or inflammatory stages ; 
indeed, harm may not improbably be done by exciting and frightening the 
child. The more at rest the cord is allowed to remain, the better chance is 
there of absorption of the inflammatory material and recovery of function of 
nerve elements. 

In the chronic stage good may be done by gentle friction applied to the 
muscles, and by the application of blisters or the actual cautery over the 
region corresponding to the disease. A change to the seaside, the patient 
being wheeled out in the open air in a recumbent position, is likely to expedite 
recovery by improving the general health. 

Hereditary Ataxic Paraplegia, or Friedreich's Disease, is the name 
given to a form of ataxia which commences for the most part during early 
life, and which tends to affect several members of the same family. It most 
commonly appears during the period of the second dentition or from that on 
to puberty. The most characteristic feature of the disease is a reeling gait, 
the patient swaying about both in walking and standing, a condition made 

P P 



578 Diseases of the Nervous System 

more apparent by the closure of the eyes. As in other forms of ataxy, the 
knee-jerk is quickly lost. Failure of muscular power takes place as the 
disease progresses. The muscles of the head and neck as well as the arms 
become affected mostly with tremor, so that when a voluntary movement is 
attempted irregular jerky movements take place. Nystagmus is a common 
symptom. The progress of the disease is very slow. The lesion in the 
cord consists of sclerosis of the posterior and lateral columns ; the anterior 
column may also be affected. 1 



Anterior Polio-myelitis. Acute Atrophic Paralysis. 
' Infantile Paralysis ' 

Etiology. — The disease, which is usually known by the name of ' in- 
fantile paralysis,' occurs most frequently during early childhood ; but, as a 
form of paralysis exactly similar occurs during the later years of childhood 
and also during adult life, the name certainly ought to be abandoned. It 
most frequently occurs during the first three years of life, at least four-fifths 
of the cases occurring at this period (Gowers). It is less frequent during the 
first six months than it is during the last half of the first year and during 
the second. It is by no means a rare disease in older children. 

Very little is known as to its cause, and, while it occurs both in the strong 
and weakly, in the majority of cases in our experience it has been met with 
in typically healthy children, with a good family history, and who could not 
be said to ail anything ; and no reason could be assigned for its onset. It 
certainly appears to be commoner during the warm quarter of the year than 
at any other period. It appears occasionally to follow exposure to cold, 
such as sitting on damp grass, or it may apparently result from an injury. 
It follows occasionally as a sequela of measles, scarlet fever, typhoid, 
pneumonia, and acute diarrhoea. Dentition has been credited with being a 
cause, but of this there is not sufficient evidence. Perhaps the most likely 
predisposing cause is over-exertion in children who have only recently learnt 
to use their legs, though this can hardly be a cause in children under a year 
old. There has been a growing belief during the last few years that the 
inflammatory lesion in the cord is due to the action of toxines produced by 
micro-organisms. No specific micro-organism has at the present time been 
isolated ; the evidence of the bacterial origin of this disease rests upon the 
fact that in rare cases limited epidemics have been observed, and that other 
diseases — such as posterior basal meningitis, tetanus, and diphtheritic paralysis 
— are due to toxines formed by bacterial action. Epidemics have been de- 
scribed by Medin, W. Pasteur, Buzzard, and others, but it is a noteworthy 
fact that in some of the cases neither the symptoms nor the post-mortem 
findings exactly corresponded with typical cases of anterior polio-myelitis. It 
is important to note that some of the patients suffered from the prevailing 
fever, but not from paralysis. In a case of our own recorded below there 
was a feverish attack from which the patient recovered, followed by a similar 
attack, associated with paralysis of one leg. 

1 See Gowers, Diseases of the Nervous System, vol. i. ; and J. S. Bury, Brain, July 
1886. 



Acute Atrophic Paralysis 579 

Symptoms. — The course of the disease may be conveniently divided into 
stages, and, following Gowers, they may be stated thus : 

1. An initial stage, during which the paralysis occurs, usually pre- 
ceded or accompanied by fever, and lasting a few hours to a week. 2. A 
stationary period, which lasts from a Aveek to a month. 3. A period of 
'regression,' during which the paralysis disappears in certain of the affected 
muscles, leaving others still paralysed ; this stage usually occupies one to 
six months. 4. A chronic stage, during which atrophy occurs and deformities 
and contractures are developed. Some improvement may take place during 
this stage. 

1. The initial stage is usually ushered in with fever, restlessness, con- 
vulsions, muscular twitchings, and cerebral disturbance. The severity of the 
attack differs much in different cases ; it has rarely been closely observed, 
being usually attributed to dentition or gastric disorder, and only when the 
paresis has supervened has the importance of the attack been recognised. 
The pyrexia is rarely high, perhaps 101 ° to 102 ; there may be muscular 
twitchings of the face or the affected limb ; drowsiness, delirium, or convul- 
sions may be present. The acute attack may be entirely absent, or, what is 
more likely, ill-defined, so that it is overlooked by the friends, and the only 
history obtained is that the child was put to bed well, and that in the morn- 
ing a limb or limbs were found powerless and limp. The paralysis is usually 
first noticed after the acuteness of the attack has passed, and in infants it is 
very likely to be overlooked at first, or thought to be due to weakness only. 
The paralysis reaches its height at once, or at any rate in a few days or 
under a week. It is difficult to say what proportion of cases die in this stage, 
for probably the nature of the disease would not be recognised, and the 
attack would be attributed to ' convulsions ' or the early stage of some acute 
disease. Nevertheless, such cases have been recorded, and lesions found in 
the grey matter of the spinal cord. 

It sometimes happens that two members of a household are attacked 
with fever, &c, one gets well and the other is seized with characteristic 
'infantile paralysis' affecting some group of muscles. In other instances 
two or more members of a household within a few days of one another suffer 
from attacks associated with paralysis of the anterior polio-myelitis type. 

There seems to be no relation between the severity of the initial attack 
and the extent of the paralysis which follows it, some of the most extensive 
and severe paralyses being accompanied by hardly any febrile disturbance. 
It is not certain whether the febrile symptoms are due to the inflamma- 
tory lesion taking place in the cord, or if the lesion in the cord as well as the 
fever and convulsions are the result of some unknown process going on in 
the body. 

In some cases there is an acute attack, which passes away, leaving no 
definite paresis : another similar attack follows, and when this clears up a 
paralysis is noted. This was the case in the following instance. A boy 
aged two years, a patient of Dr. Sutcliffe of Stalybridge, was quite well and 
running about, when one day he was taken suddenly ill, crying, vomiting, and 
feverish ; the following evening he was convulsed ; he was put to bed and 
continued ill for two or three weeks with apparently some brain trouble ; this 
attack left him very weak ; but he gradually recovered and was able to run 



580 Diseases of the Nervous System 

about again. He continued well for two months, when the same symptoms 
returned ; he cried with pain, there was vomiting and fever, followed by con- 
vulsions ; he remained ill for fourteen days, and just as he was getting up 
and about again it was noticed that his right leg was paralysed. When seen 
two months after, there was wasting and paresis of the right buttock, thigh, 
and dorso-extensors of the foot. 

While in typical cases there is more or less complete loss of motor power 
without the sensory nerves being affected, yet it sometimes happens there is 
severe pain, and in rarer instances anaesthesia. It is certain in these exceptional 
cases the lesion is not absolutely confined to the anterior horns. There may 
be severe shooting pains before the onset of the paralysis, or the pains may 
remain and there may be hyperesthesia or pain in handling the limb. Such 
cases readily pass muster as 'hysterical,' especially in girls, but the definite 
paralysis which remains makes the diagnosis only too certain. The following 
case of severe anterior polio-myelitis commenced with severe pain : 

Alice D., set. 10^ years. Quite well till October 1896, when she had two boils on her 
back which troubled her a good deal. On October 31 she did not feel well and had head- 
ache ; the next day she was seized with violent pains in the back, arms, and legs, and 
had a temperature of 103 ; this continued for three days, when it was noticed there was 
almost complete loss of power in her back, arms, and legs ; the pain was worst in the legs, 
making her scream loudly. She gradually regained power in her back and arms, so that 
she can sit up and feed herself ; the left leg remained completely paralysed from the rotators 
of the hip downwards, the right leg has regained slight power. 

In another case seen with Dr. Sheldon of Macclesfield, a girl of 10 years 
had an indefinite febrile attack, followed during convalescence by loss of 
power in the muscles of the right hip ; there was some pain complained 
of, and there was hyperesthesia. The paresis of the muscles affected was 
permanent. 

2. After the paralysis has reached its fullest extent, a period during which 
the paresis of the muscles is stationary ensues, varying from two weeks to 
six weeks or two months. At this time the affected muscles are limp and 
powerless, so that the limb or limbs hang quite useless and flail-like. In 
the more severe cases almost all the muscles in the body appear to be 
involved ; the child cannot sit up, its head falls to one side through paresis of 
the muscles of the neck, its cry is weak or almost lost from weakness of 
the diaphragm and intercostals, its respiration is shallow and rapid, and its 
limbs relaxed and motionless. The paralysis may be confined to one limb 
or a group of muscles in a limb : thus an arm may hang useless by the side, 
and if raised above the head falls flail-like by the side. One or both legs 
may be powerless, and may be flexed, extended, or rotated without any 
resistance from the tonus of the muscles. The muscles of the neck, back, 
and intercostals may be affected. Hemiplegia is rare. The reflexes, both 
superficial and deep, are lost, so that tickling the sole of the foot or per- 
cussing the patellar tendon meets with no response. It is difficult to judge 
if there is any loss of sensation or at least sensory paralysis. In the most 
severe cases we have noticed that sensation is not as acute as usual : a spoon, 
which to a normal skin is unbearably hot, can be borne without eliciting 
any expression of pain on a recently paralysed foot, and in the same way a 
painfully severe application of faradaism will be borne without flinching. 



A cu te A tropJi ic Pa ralysis 581 

It must be borne in mind, however," that the circulation in the skin is 
interfered with by the lesion of the cord, and, moreover, it is much more 
difficult to test the sensations of an infant six or eight months old than it is 
those of an adult. The functions of the sphincters of the bladder and rectum 
are rarely interfered with. We have, however, seen one case of a boy aged 
four years where for a few days after the onset of the paralysis, which affected 
both legs, a catheter had to be used twice a day on account of paralysis of 
the bladder. 

The irritability of the muscles to the faradic current becomes lessened 
during the course of the first week or ten days, and is usually entirely lost in 
those muscles where a permanent paralysis has taken place, and thus the 
careful testing of the muscles may be of importance for prognosis. To the 
continuous current the muscle irritability is increasing during this period, 
though it gradually is lessened as the muscles waste, and may disappear 
during the atrophic period. The quality of the muscle irritability differs 
from normal, presenting the ' reaction of degeneration ' l due to the degenera- 
tion of the nerves to the affected muscles. 

In the majority of cases one limb only is affected, and one group or 
groups of muscles more affected than others ; in some few cases the paresis 
at first involves not only the limbs, but the diaphragm and intercostals. The 
most severe case coming under our notice was the following : 

A girl of nine months was quite well and healthy till June 21 ; she was able to raise 
herself up in her cradle, and could support herself with help on her feet. She was suddenly 
seized with convulsions in which her face and arms twitched ; this was followed by a dis- 
charge from one ear, and at the same time she was completely prostrated, her voice was 
hardly audible, she lay in bed perfectly motionless, except a rolling of the head from side 
to side. She was admitted to hospital on July 30, when the following notes were made by 
Dr. Kershaw : ' She is a well-nourished child ; lies in bed quite helpless'; the lower ex- 
tremities are completely paralysed ; there appears to be some loss of sensation, as only the 
application of the strongest faradic current appears to cause pain. She can bear without 
crying the contact of a hot spoon, too hot to be held in one's own hand ; can move right 
arm at the shoulder and elbow, but not the hand ; the left arm is completely paralysed 
though she seems to be able to move the fingers slightly. There is paresis of the inter- 
costals, respiration mainly abdominal. No reactions to the strongest faradic current were 
obtained in the legs, some response could be obtained in the flexors of the forearm. She 
died of pneumonia on August 7, forty-seven days after seizure ' (see p. 584). 

3. The stage of *• regression' or improvement now commences, the im- 
provement continuing for several months, many muscles being completely 
restored, while others become more and more flabby and atrophic. In rare 
instances all the paralytic muscles may recover. The child's health at this 
time is usually good, it is as bright and cheerful as usual, and there is apparently 
nothing amiss with it except its paralysis. The muscles, which are gaining 

1 In a normal condition the weakest galvanic current which causes contraction of a 
muscle is a descending one — i.e. when the anode or positive pole is on the spine, while the 
kathode or negative pole is on the muscle, the contraction occurring on closure of the 
current. This is the kathode closure contraction, K.C.C. When there has been degene- 
ration of nerves, contraction may occur more readily with an ascending current — that is, 
with tbe anode on the muscle : the anode closure contraction, A'.C.C. Normally, K.C.C. 
is greater than A.C.C. ; in nerve degeneration A. C.C. may be equal to or greater than 
K.C.C. Normally, the opening anodal current, A.O.C., is greater than the kathodal 
opening current, but this may be reversed in disease. 



58: 



Diseases of the Nervous System 



in power, respond more readily to the interrupted current than at first, while 
the atrophic muscles fail entirely to react. 

4. After some months improvement ceases, or, at least, any improvement 
which takes place six months after the onset is usually very slight indeed. 
The atrophy mostly goes on, and certain contractures, especially affecting 
the leg below the knee, leading to deformities, are apt to take place. At this 
period it is possible to make a forecast of the amount of paralysis which is 
likely to be permanent, and take stock, as it were, of the real damage which 

has taken place, which is pro- 
bably much less than at first 
appeared likely. This per- 
manent paralysis may affect 
a whole limb, though it rarely 
does this, some groups being 
entirely powerless, others 
only slightly weakened or not 
affected at all. 

Sometimes the groups af- 
fected are associated together 
in their actions, as when the 
upper arm type of Erb is 
present, the deltoid, spinati, 
biceps, and supinators being 
affected, while the muscles 
of the forearm, excepting the 
supinators, escape, the lesion 
in the cord being situated on 
a level with the fifth and sixth 
cervical roots (see fig. 129). 
It is important to remember 
that the groups have no rela- 
tion to their peripheral nerve 
supply, such as would be 
present if the paralysis was 
extra-spinal. Very often the 
muscles paralysed, have no 
relation to one another, being 
picked out, as it were, at 
random. 

In the lower limb the 
muscles below the knee usu- 
ally suffer more complete paralysis than those of the thigh or buttock. The 
peronei usually suffer most, the result being that the heel is drawn up and the 
foot turned inwards (talipes equino-varus) by the unbalanced action of the 
gastrocnemius ; as time goes on the contracted condition of the calf muscles, 
aided by the shortening of the leg, becomes permanent in consequence of a 
fibroid degeneration taking place, and the foot can no longer be dorso-flexed. 
In the same way talipes valgus may be produced by paralysis of the tibialis 
anticus, more rarely talipes calcaneus by the paralysis of the gastrocnemius. 




Fig. 128. — A. H., aged g years. Acute Atrophic Paralysis, 
legs, back, and arms affected. 



Acute Atropine Paralysis 



583 



Both legs below the knee may be paralysed, both extensors and flexors ; and 
the patient cannot stand, but progresses by crawling on his hands and knees, 
dragging his wasted legs after him. 

Of the thigh muscles, the rectus, vasti, and adductors are more often 
paretic than the hamstrings, and thus flexion of the knee may result and 
become permanent. The gluteal muscles and rotators of the hip are often 
weak, so that the child in walking gives way at the hip. 

In the upper extremity the muscles of the shoulder suffer most frequently, 
the deltoid being especially prone to attack ; usually the supra- and infra- 
spinati, biceps, triceps, and supinators are associated together : in such cases 
the shoulder droops from the weight of the arm, and the head of the humerus 
may slip readily out of its socket. The serratus magnus, pectoral muscles, 
and intercostals may also be 
affected. The forearm muscles, both 
extensors and flexors, together or 
singly, may be affected ; less often 
those of the hand. Contractures 
are less often present in the arms 
than in the legs. 

The muscles of the spine, sacro- 
lumbalis, &c, and those of the 
neck and diaphragm, are rarely 
permanently paralysed. Lordosis 
is present if the sacro-lumbalis is 
weakened. Lateral curvature may 
be present. In severe cases the 
paralysis is very extensive, render- 
ing the patient very helpless. Thus 
in the case of the boy figured 128 
and 129, he could manage to sit up 
for a short time, if helped, by sup- 
porting his trunk with his hands 
and arms. Both legs were almost 
completely paralysed. The inter- 
costals were partially paralysed, and 
so also were the arms. 

The paralysed muscles are always atrophied, though at -times much sub- 
cutaneous fat may give a delusive appearance of solidity to the muscle. In 
the most wasted muscles there is a complete loss of faradic irritability : there 
is usually more or less present in those only partially paralysed. The irrita- 
bility to the continuous current gradually disappears as atrophy progresses, 
and in the wasted muscles becomes completely lost. 

Arrest of development of the limbs which are paralysed also takes place ; 
the bones appear to grow more slowly on the paralysed side. Other bones 
such as the ribs and pelvis may be affected. The joints often become more 
movable from relaxation and stretching of the ligaments, as well as from the 
loss of support afforded by the normal muscles ; the articular ends may 
become deformed. The circulation through the skin of the paralysed limbs 
becomes slow, the surface has a blue or purplish appearance and feels cold 




Fig. 129. — A. H., aged g years. Acute Atrophic 
Paralysis ; he can sit up by help of hand ; right 
shoulder muscles paralysed (upper arm type). 



584 Diseases of the Nervous System 

to the touch. Chilblains and ulcers are apt to form on the paralysed limbs, 
and be slow to heal. The bones themselves frequently degenerate ; in 
some cases little true bone may remain, fat taking the place of the osseous 
tissue. Injuries, operative or accidental, of such limbs are slow in healing ; 
on the other hand, acute inflammations rarely attack the tissues. 

Pathology. — There is an acute inflammation, the greatest stress of which 
falls on the anterior .cornua of the grey matter in the cervical and lumbar 
enlargements. In severe cases the grey matter of the dorsal cord is also 
affected. There is s.trong reason to believe that, in some cases at least, the 
inflammation is not confined to the anterior cornua, but involves more or less 
the whole cord ; but the principal damage caused by the effusion of blood and 
inflammatory products occurs in the most vascular part of the cord, and this 
is in the anterior cornua where the large nerve cells are situated. During the 
acute stage of the attack, where there is perhaps a high temperature and con- 
vulsions, there is probably an inflammatory engorgement of the whole cord, 
possibly of the whole of the nervous centres : then an exudation of inflam- 
matory material takes place which leads to both temporary and perma- 
nent damage to the motor cells in the anterior cornua of the cervical or 
lumbar enlargements. During the next few months an absorption of inflam- 
matory material and perhaps also repair of damage by the formation of new 
nerve fibres or cells goes on, while a certain amount of muscular power which 
has been lost is regained. Finally a sort of cicatrisation or shrinking takes 
place, leaving a permanent paralysis of the muscles supplied by the nerve 
centre which has been destroyed. 

Very few observations have been made on the cords of those dying during 
the acute attack or at the onset of the paralysis. In Drummond's case, 1 that 
of a child of five years who died in a few hours, the vessels supplying the 
anterior horns were distended with blood, the microscope showing minute 
extravasations of blood and changes in the nerve elements. A case re- 
corded by Charlewood Turner, dying six weeks after the attack, showed 
softening of the anterior horns, spots where the grey matter had undergone 
complete degeneration, and an exudation of leucocytes had taken place from 
the vessels. In our own case, p. 581, similar changes were visible in the grey 
matter of the lumbar, cervical, and dorsal portions of the cord, and changes 
such as effusion of leucocytes from vessels were noted in the white matter, as 
well as the grey. Moreover, even in the medulla it was evident that an 
engorgement of the vessels had taken place. 

Degenerative changes take place in the nerves which are connected with 
the damaged centres in the cord ; the muscles also waste ; their connective 
tissue becomes hypertrophied, so that in extreme cases very few muscular 
fibres are left. The muscles which antagonise the paralysed muscles mostly 
also waste, their muscular fibres becoming replaced by connective tissue. 

Diagnosis. — The diagnosis during the acute attack is always difficult, 
mostly impossible ; the fever, delirium, and convulsions sometimes present 
naturally suggest some cerebral disease such as meningitis or the onset of 
scarlet fever or pneumonia. It is only when paralytic symptoms present 
themselves that the diagnosis is made ; even then the paralysis may be over- 
looked, especially in young children, it being supposed that the child is 

1 Brain, April 1885. 



Acute Atrophic Paralysis 585 

simply weak as "the result of the acute attack. When once the paralysis has 
set in, diagnosis is easy, though when paraplegia is present the distinction 
between transverse myelitis of the lumbar region and polio-myelitis may 
not be easy. In transverse myelitis there will be certainly loss of sensation ; 
this is said not to occur in cornual myelitis, though in the case recorded 
(p. 581) there was undoubted slight loss of sensation. In transverse myelitis 
of the dorsal region, its commonest seat, there will be no loss of faradic 
irritability, and after a few days or a week the reflexes will return and become 
excessive, and ankle-clonus can usually be obtained. 

In cerebral paralysis there is no loss of faradic irritability, and no mus- 
cular wasting takes place. 

Treatment. — -The treatment of anterior polio-myelitis in the early stages 
is that of an acute inflammatory lesion of the cord. The child must be kept 
as quiet as possible in bed, given a milk diet, and good may possibly be done 
by applying mustard poultices to "the spine. If there is fever, aconite and 
bromide of potassium may be given. When the acute stage has passed away, 
and the child is left in a prostrate condition, the greatest care must be taken 
to keep the child at rest as much as possible, all excitement of every kind 
being avoided. It must be borne in mind that, in patients dying many- 
weeks or even two or three months after the onset, evidences of the inflam- 
matory lesion may still be found in the cord, and during this period absorp- 
tion of inflammatory material is going on, and the object to be aimed at in 
treatment is to secure the recovery of as much of the damaged cord as 
possible. A variable amount of nerve tissue has been certainly irretrievably 
damaged, but some of the damage done is recoverable, and the more the 
general health is maintained and the child kept at rest} the more is it likely 
that recovery will take place. 

It may be doubted if there are any medicines which have any direct 
influence over the nutrition of the cord or directly influence any morbid 
processes going on. Perhaps the most likely drugs to be of service are 
sedatives such as belladonna and bromides in combination with iron or 
quinine. 

The question of how soon should massage or electrical treatment be 
begun is an important one ; for, on the one hand, the paralysed muscles are 
quickly wasting on account of their nerve centres being damaged, but on 
the other hand the disturbance of the child, the fright and excitement of 
the daily application of the battery, are not unlikely to do harm. The 
application of the battery current is hardly likely to modify or favourably 
influence the lesion in the cord, but it may help to maintain the nutrition of 
the muscles while recovery is taking place in the cord. On the whole we 
are inclined to believe that gentle rubbing or massage of the paralysed 
limb or limbs may be practised from the first, and voltaic currents may be 
used within a month or six weeks. It is wise to begin with a very weak current, 
at first using large wetting sponges as electrodes, and frequently interrupting 
the current, which after a few applications should be just strong enough to 
secure a contraction. The application should be made daily for many 
months, especial care being taken to select the paralysed muscles in the limb. 
An important part of the treatment is to encourage the patient to put 
forth as much voluntary power as possible, and he should constantly try to 



5cS6 



Diseases of the Nervous System 



use the weakened limb. We believe that systematic attempts to use the 
paretic muscles, combined with shampooing of the limb, are more likely to 
promote recovery than any electrical applications. The circulation in the 
paralysed limb is certain to be slow and defective ; friction of the skin, with 
kneading of the muscles, is certainly beneficial ; while a well-selected series 
of movements attempted on the part of the patient, or carried out by an 
attendant, assists the return of power in the muscles. These measures must 
in most cases be persevered in for many months, if not years, in the hope of 
improvement. The paralysed limbs must be warmly clad and carefully pro- 
tected from cold. 

Much may be done in the chronic stage by means of mechanical devices 
such as the application of artificial muscles and splints to correct deformities 
and support the limb. Division of the tendo Achillis, plantar fascia, and 




Fig. 130. — Peter L., aged 10 years. Acute Muscular Atrophy. 

other resisting structures is often required. For useless flail-like limbs the 
question of excision of joints to procure greater stability, or even of amputa- 
tion, has to be considered. {Vide also Chapter on Talipes.) 

Chronic Spinal Muscular Atrophy. Progressive Muscular Atrophy. 
This disease for the most part belongs to adult life, and but rarely occurs in 
children ; the progressive muscular atrophies most common during early life 
are those classed with the muscular dystrophies (see p. 588). The following- 
case illustrates this somewhat rare disease. 

Peter L., aged 10 years. Mother stated that two months ago she noticed he could not 
button his trousers or coat, about the same time she noticed that he walked badly ; his 
arms and shoulders have been getting weaker, and he has difficulty in taking his coat off. 
On admission it was noted that the thenar and hypothenar eminences of the right hand were 
extremely wasted, indeed almost entirely disappeared ; the interossei were much wasted. 
There was similar wasting in the left hand, but not so marked. The fingers of the right 



Chronic Spinal Muscular Atrophy 587 

hand were extended at the metacarpophalangeal joints, thus giving the hand a ' claw-like ' 
appearance. There was wasting of the right forearm and upper arm, both flexors and ex- 
tensors. The deltoid was not much affected. There was wasting of the muscles of the sole 
of the foot of the right side, giving it a hollowed-out appearance, the right great toe was 
dorso-flexed at the metatarso-phalangeal joint, the calf and muscles of the legs were flabby, 
but not much wasted. The muscles of the left foot were wasted, but less than the right. 
There were no fibrillar twitchings in the muscles, the knee-jerks were increased, no ankle- 
clonus, the elbow-jerk was present. The galvanic reactions of both hypothenar eminences 
showed A.C.C. > K.C.C. Interossei A.C.C = K.C.C. on the right side, K.C.C. > A.C.C. 
on the left. No contractions with a strong faradic current could be got on the right hypo- 
thenar and thenar eminences ; a slight contraction on the interossei of right and muscles 
of the left hand. The muscles of the scapulae and back are flabby, but there is no definite 
wasting or paresis. The face wore a more or less expressionless appearance, but there 
was no paresis or actual muscular wasting. 

Neurologists usually distinguish between the ' hand-shoulder ' type and the 
foot or 'peroneal' type of chronic spinal muscular atrophy. The first of 
these types is for the most part a disease of adult life, while the peroneal type 
of Tooth mostly commences before puberty. In the case related the wasting' 
and weakness of the hand and feet commenced about the same time. Both 
types have many symptoms in common ; there is gradual weakness, and 
marked wasting of certain groups of muscles, other groups of muscles 
becoming gradually affected. Usually, but not always, there are idiopathic 
fibrillations of the affected muscles, the faradic irritability disappears, the 
galvanic irritability is lessened and altered in quality (reaction of degenera- 
tion). In the hand-shoulder type usually the wasting commences in the 
thenar and hypothenar eminences of one hand, gradually involving the arm 
and shoulder and also the muscles of the hand of the opposite side. In the 
peroneal type, the wasting usually begins in the extensor of the great toe, 
the extensor of the toes, the peronei or small muscles of the soles of the feet. 
Gradually, ' club foot,' talipes equino-varus, makes its appearance. The 
paresis and wasting may slowly spread to other muscles. We have known a 
slight degree of the peroneal type present in several members of the same 
family — namely, a hollowing out of the sole of the foot, a paresis of the peronei 
with a resulting over-action of the gastrocnemius, and a marked dorsi- 
flexion of the great toe (see fig. 130). The 'family toe ' is spoken of as a joke ! 
This condition is by no means uncommon, and may remain stationary for 
years at least. 

Peripheral Neuritis 

We have already referred to the fact that a form of paresis or paralysis 
may accompany or follow an attack of diphtheria. The ptomaines present 
in the blood give rise to a degeneration or neuritis of the terminal nerve 
fibres. While it is far more common after diphtheria than any other disease, 
it occurs also after influenza and some other zymotic diseases. Occasionally 
peripheral neuritis accompanies rheumatism and chorea, and we have also 
noted it when no history could be obtained of any disease preceding the 
paralysis. That it occurs in connection with influenza we feel sure ; in one 
case coming under our notice paresis of the ciliaris muscles occurred in 
a boy aged seven years during convalescence from influenza, and where 
diphtheria could be excluded with certainty. In another case of ours 



588 Diseases of the Nervous System 

of pneumonia which appeared to be due to influenza, paresis of the inter- 
costals, diaphragm, and extremities supervened during convalescence, and 
ended fatally. 

The Muscular Dystrophies 

In this group the lesion is regarded as primarily muscular, there is a 
tendency to occur in the same family, and they are specially characterised by 
wasting of the muscular tissues. The pseudo-hypertrophic form is by far 
the most common. 

i. Pseudo-hypertrophic Paralysis. — Very little is known about the 
etiology of this particular disease: It is apt to run in families, and, strange 
to say, while it affects boys far more frequently than girls, in some 
families it affects the boys only, and in others it affects the girls. In 
some cases there is a family history of the disease, and it appears it may 
be transmitted through the female side without the women themselves 
being affected (Gowers). In one of our own cases the patient's brother 
was an epileptic, but it rarely happens that any family tendency to nervous 
disease exists. 

Symptoms. — In the majority of cases symptoms first make their appearance 
during the second or third year, the child being late in learning to walk, the 
parents attributing this to backwardness or weakness. In some cases the 
symptoms of weakness are noted after the child has been walking some time, 
perhaps as late as the six or seventh year. The early symptoms are those of 
weakness in the legs. As Gowers well put it, ' these children usually walk 
late, also walk clumsily, fall with ease, and rise with difficulty.' If placed 
upon the ground they either cannot get up without help, or, what is more 
likely in the early stages, they are obliged to use their hands in rising, 
pushing themselves off the ground and catching hold of chairs or table- 
legs to help themselves up. They walk clumsily, with a swaying gait, are 
quickly tired, and have to be wheeled about in a perambulator long after 
children of a corresponding age are running about and going walks. 

In other cases the friends pay little heed to the backwardness in walk- 
ing, but are struck with the size of the calves or perhaps apparent stoutness 
of the child. At four or five years of age, often earlier, the muscular hyper- 
trophy is conspicuous. The muscles of the calf are strikingly enlarged, firm 
and hard ; as are usually also the glutei and lumbar muscles— less often 
the hamstrings, extensors of the knee, and dorso-flexors of the foot. Of 
the other muscles, the infra-spinatus is, next to the calf, the most frequently 
enlarged, and, as Gowers points out, this enlargement of the infra-spinatus 
may be of diagnostic importance. The deltoid and supra-spinatus are often 
enlarged, the latissimus is mostly wasted, and the rule is that the other 
muscles of the upper extremity are wasted rather than hypertrophied. In 
rare cases the masseters and muscles of the tongue are enlarged. 

The muscles, whether enlarged or wasted, are weak, and it is this 
weakness of certain muscles which gives rise to the characteristic move- 
ments of the child. The waddling gait is the result of weakness of the 
gluteus medius and extensors of the hip generally. The difficulty in rising 
from the floor is due to the paresis of the extensors of the knees in the 
first part of the act, and the extensors of the hips in the second, the patient 



Pseudo-hypertrophic Paralysis 



589 



assisting the extension of the hips by placing his hands on his knees, and 
' climbing up himself by grasping his thighs alternately with his hands. 

Later in the disease the enlarged muscles 
contract, the earliest to shorten being the calf 
muscles, so that a talipes equinus is produced. 
Later on, the knee and elbow may become 
flexed. 

The weakness of the extensors of the hip 
produces a certain amount of lordosis or 





Fig. 132. — Same case as fig. 131 ; showing Hyper- 
trophied Deltoid and Infra-spinati. 



curvature of the spine with the concavity 
backwards, the patient assuming this position 
in order to maintain his balance. (See figs. 

131, 132.) 

In the last stages the patient becomes 

entirely bedridden and helpless, partly on 
account of the paresis of the muscles, partly also in consequence of 
the muscular contractions producing talipes equinus. In this stage the 
enlarged muscles mostly waste, and consequently lessen in size. The electric 
irritability of the muscles is unaffected both to the continuous and interrupted 
current at first ; later, as the muscular fibre wastes, it gradually disappears. 



Fig. 131. — A case of Pseudo-hyper- 
trophic Paralysis in a boy of ten 
years ; showing enlarged calves and 
slight talipes equinus. 



590 Diseases of the Nervous System 

The knee reflex, at first normal, gradually disappears for a similar reason. 
In children suffering from this disease the mind is often weak. 

The progress of the disease is slow, extending over many years, the 
patient possibly being helpless and bedridden, having almost lost the .use 
of his legs. He is even unable to sit up on account of the wasting of the 
spinal muscles, but is usually able to use his hands to the last. Death is 
apt to take place from bronchitis ; this was the case in one of our own 
cases who lived to the age of twelve years, the disease having existed at 
least eight years. In the majority of cases where the disease begins early, 
death takes place soon after puberty, at any rate among the hospital patient 
class ; under the most favourable circumstances, where great care is taken 
of the patient, life may be prolonged to a greater age. The course of the 
disease appears to be slower in girls than boys. 

Diag?iosis.- — This is most difficult in young children in the early stages, 
and in the absence of typical enlargement of the calf muscles and infra- 
spinati. A fat, yet weakly, child of three or four years of age, who is late in 
walking and more or less rickety, may somewhat simulate a case of pseudo- 
hypertrophic paralysis in its gait, and in the difficulty of getting up. Usually 
there is sufficient enlargement and hardness about the gastrocnemii to make 
the diagnosis tolerably clear, especially if there is corresponding enlarge- 
ment of the infra-spinatus and wasting of the latissimus dorsi. In the 
absence of muscular enlargement, especially if there is wasting, the disease 
maybe confounded with idiopathic muscular atrophy ; but the latter disease 
is rare before puberty, is apt to affect the face and hands, and to avoid the 
calf muscles. A fragment of muscle may be obtained, and muscular atrophy 
can be excluded if there is an excess of fibroid and fatty tissue present. 

Prognosis. — The cases slowly, but surely, get worse ; the weakness year 
by year increases, though a certain amount of temporary improvement may 
take place. We have seen cases which we believe to have been examples of 
this disease in a mild form get entirely well. 

Pathology. — The disease has been conclusively proved by the careful 
examinations of Gowers and others to be primarily a disease of the muscles, 
and if changes take place in the spinal cord they are only secondary. There 
is an overgrowth of connective and fatty tissue ; it is the latter which forms 
the enlargement of the muscles, and it is the absence of muscular fibres 
which renders them weak. The shortening which takes place is due to the 
contraction of the fibrous tissue. 

Treatment. — Medicines, except those which are likely to improve the 
general health, are of little use. The treatment which has proved itself of 
the greatest use in checking the progress of the muscular wasting is exercise 
of the affected muscles by well-arranged movements, which the patient is 
encouraged to perform, and friction, with passive movements, so as to pre- 
vent shortening of the muscles. We have certainly seen cases which have 
been admitted into hospital improve in no inconsiderable degree under this 
treatment. It is needless to say it must be systematic and carried out with 
the greatest patience, if it is to be successful. 

2. Juvenile Form of muscle Atrophy (Erb). — This form of muscle 
atrophy resembles in some respects pseudo-hypertrophy of muscles, and some 
cases occur in which it may be difficult to say to which class they belong. 



Muscle Atrophy 591 

We note here also the tendency to run in families, as in pseudo-hypertrophic 
paralysis. There is weakness and wasting of certain groups of muscles. 
The upper-arm muscles are usually first affected — namely, the biceps, triceps, 
and supinator longus ; the lower part of the pectoralis major and minor, and 
also the serratus, trapezius, latissimus and rhomboidei often also suffer more 
or less atrophy. The deltoids, infra- and supra-spinatus, usually escape ; in 
some cases they have been described as hypertrophic. The muscles of the 
forearm and hand usually escape. In the legs, the quadriceps, the flexors 
of the hip, and glutei, the peronei and tibialis anticus may be affected. The 
muscles of the spine, especially the sacro-lumbalis, may be wasted more or 
less. The electric irritability of the muscles is lessened in proportion to the 
wasting. There is no reaction of degeneration. The disease is essentially 
chronic. 

3. Infantile Muscle Atrophy of the Pace (Landouzy, Dejerine). — This 
form is closely related to (2), if not actually belonging to the same class. 
This disease appears to be almost entirely observed in children. There is 
wasting of the muscles of the face, especially the orbicularis oris, zygomatics, 
and frontalis. The expression of face is peculiar, and there is a curious 
alteration of expression if the child laughs or smiles, on account of the 
paralysis of the zygomatics which elevate the angles of the mouth. On account 
of the weakness of the orbicularis oris, the lips are separated and the lower lip 
protrudes. The tongue, eyeball muscles, and muscles of mastication escape. 
The course, like that of other diseases of this group, is chronic and pro- 
gressive. 

Myotonic. Thomson's Disease 

The first symptoms of this rare disease are first observed during child- 
hood, and apparently persist through life. The disease is apt to affect 
several members of the same family, and can be traced back through several 
generations. The characteristic symptom is that whenever the patient 
attempts to move, the muscles assume a condition of cramp or tonic spasm. 

After a few attempts to use his limbs the patient succeeds in gaining 
command of the muscles, and the spasm does not return till after a period of 
rest. No treatment appears to be of any use. 

Our colleague Mr. Whitehead recently (1898) showed us a little girl with 
a condition of the skin of the thigh and of the underlying adducta longus 
apparently exactly like that seen in cases of Dupuytren's contraction in the 
hand. It has been slowly coming on, and no cause for its onset was known. 
The femoral lymphatic glands were enlarged, and possibly the affection may 
have been one primary of the lymphatics, but there appeared no doubt that 
the muscles were definitely implicated in the sclerosing process. 



59 2 Diseases of the Genito-nrinary System 



CHAPTER XXVII 

DISEASES OF THE GENITOURINARY SYSTEM 

Abnormal Conditions of Urine 

We have already referred to the fact (page 7) that while infants and children 
pass a smaller quantity of urine per diem than adults, yet relatively — for their 
weight — they pass more, and this is also true of the urea excreted. The 
amount of urine passed is influenced by slighter causes, such as cold feet, 
chills, indigestion, &c, during early life than later. Speaking generally, the 
urine excreted by children is of a paler colour, lower specific gravity, and is 
less concentrated than the urine of adults. The amount passed is increased 
in such conditions as diabetes mellitus and insipidus, while it is diminished 
in acute nephritis and most febrile conditions. 

Iiithaemia. TTricacidaemia. — We have quoted the observations of 
Carriere and Monfit (page 7) to the effect that both actually and relatively 
less uric acid is excreted by children as compared with adults ; but we must 
add that this is not in accordance with the observations of some other authors. 
Thus Haig says, ' for while in adults urea is formed in about the proportion 
of three or four grains per pound of body-weight per day, uric acid in its 
normal relation to urea of 1 to 35 would be about '09 to *ii grain per pound 
per day ; in a child 3 or 4 years old urea may be as much as 9 or 10 grains 
per pound and uric acid -27 to -3 grain per pound of body-weight.' 

Unfortunately the estimation of uric acid in the urine is a complicated 
process and there is no clinical method of ascertaining with certainty if the 
uric acid in the urine is above or below the normal amount. Uric acid is 
only in evidence when it is deposited in fine reddish crystals, or as a bulky 
precipitate in the form of urates which separates from the urine on cooling ; 
the degree of acidity and concentration of the urine must be taken into 
account in judging whether there is an excessive quantity of uric acid being 
excreted or not. We find a more or less copious deposit of uric acid is 
common in children convalescent from scarlet fever and other febrile 
diseases, and it is said to occur also in children who have inherited a gouty 
diathesis. This sandy deposit is seen not uncommonly in the urine of quite 
young children, and such may complain of soreness and redness around the 
meatus ; often as much as a teaspoonful of deposit may be seen in the cham- 
ber vessel in the morning. In one case we knew of, as much as a table- 
spoonful could be seen at times, especially in urine passed with a stool, or 
after some rough movement as a pony ride. In such cases presumably the 



Hcematuria 593 

uric acid has been deposited in the kidneys, pelvis, or bladder, and becomes 
dislodged by straining at stool or by rough movements. 

It is very common to find urates deposited from urine on standing and 
cooling. There is not much significance in this, though if it occurs habitually 
we should naturally be suspicious that an excess of uric acid was being 
excreted. It usually occurs when the skin has been acting freely and the 
urine is concentrated. 

Haig has collected evidence to show that an excessive quantity of uric 
acid in the blood or joints may give rise to headache, asthma, eczema, 
epilepsy, Bright's disease, rheumatism, &c, but it cannot be said that his 
views have been universally accepted in their entirety. 

In those children who pass from time to time uric acid in their urine, it 
is well to give alkalies, as citrate of potash, eff. phosphate of soda, or 
Carlsbad salts. The diet should consist for a time at least of vegetables, 
eggs and milk ; butcher's meat, beef teas, and meat extracts being avoided. 
Hseraaturia, — Blood is present in the urine in a variety of conditions, in 
general diseases as well as in local, and a difficulty may not infrequently be 
experienced in determining the source from which the bleeding takes place. 
Hsematuria or haemoglobinuria occurs at times in infants a few days or 
weeks old, who are also jaundiced ; epidemics of such cases have been 
described by Winckel and Bigelow as occurring in lying-in hospitals (p. 29). 
Two fatal cases, in which haemoglobinuria was present in infants five months 
and eight months old respectively, have been described by Hirschsprung. 
In both cases the symptoms supervened suddenly ; there was cyanosis, dark 
albuminous urine and feverishness ; in one of the cases there was dyspnoea 
(ursemic) and tetany of the hands and feet. The post-mortem showed that 
all the organs were of a dirty brown colour, and the blood in the body had 
undergone a remarkable change. Similar cases have occurred from poison- 
ous doses of chlorate of potash, but neither of these cases had been taking 
this salt. 

Hsematuria occurs in rare cases in wasted infants and young children 
from thrombosis of one of the renal veins, a consequent hemorrhagic infil- 
tration of the kidney taking place. 

We should say the commonest cause of haematuria in infants and 
children under two years of age is infantile scurvy (p. 194). In some cases 
haematuria is the first symptom ; usually spongy gums are present, but 
periosteal tenderness may be absent. Haematuria may succeed the tenderness 
and immobility of the limbs. The infant is generally pallid and is more or 
less markedly rickety. The nurse probably notices that the urine stains the 
napkin, it may be bright red, or in milder cases a yellowish-red colour. If 
the urine is passed into a vessel a red sediment of blood corpuscles settles 
to the bottom, leaving the fluid portion tolerably clear, but if much blood is 
present the supernatant liquid is bright red. We can call to mind several 
instances where infants suffering from haematuria from this cause were 
sounded for stone ; it is needless to say that no stone was found, and they 
quickly got well when their diet was changed. It is uncertain whether the 
blood oozes from the kidneys or bladder. In these cases there is no nephritis, 
only a passive oozing of blood. 

Haematuria may be the first symptom of haemophilia, and in any case 

QQ 



594 Diseases of the Genito-urinary System 

where the diagnosis is doubtful the family history should be inquired into 
for similar cases. I hematuria is often associated with purpura, and may 
occur in acute cases of variola, diphtheria, or typhus, resulting from the rapid 
blood change which takes place in these diseases. 

Hematuria may be present in acute nephritis ; in this case the urine is 
usually of a smoky tint, or more the colour of porter, but in some cases the 
colour may be bright red from the large amount of blood which it contains. 
We have seen haemorrhagic nephritis following scarlet fever, diphtheria, and 
pneumonia. A microscopical examination of the deposit which falls to the 
bottom of the glass after the urine has stood for a while will show blood and 
epithelial casts in cases of nephritis. Blood in the urine also occurs incases 
of renal or vesical calculus, more rarely in tubercular kidney, sarcoma of the 
kidney, and vascular growths in the urethra or bladder. 

Poisoning by chlorate of potash, cantharides, or turpentine as a cause of 
hematuria must not be forgotten. 

Intermittent Haemoglobinuria occurs in children as in adults, but it is 
a comparatively rare disease. 

Treaime7it. — The treatment necessarily depends upon the cause, and the 
history of the case, and other symptoms apart from hematuria, must be care- 
fully considered. It is important to exclude stone in the bladder as the 
cause of hematuria, and in all cases where the cause of the blood in the 
urine is doubtful it is wise to explore the bladder with a sound. Hematuria 
may be the only symptom of the presence of a stone. In hsematuria depend- 
ing upon an impoverished condition of blood the most important part of the 
treatment consists in improving the condition of the general health. Meat 
juice, orange or lemon juice, with dialysed iron or the perchloride, may be 
given. Styptics may also be given, though we have frequently been dis- 
appointed with their action. Of these, ex. hamamelis liq. (U.S. P.), in 5-15 
minim doses, may be given every four hours, and continued for some days. 
Gallic acid \-i grains, with aromatic sulphuric acid, is sometimes efficacious 
where hamamelis fails. Spirits of turpentine ^-3 minims in mucilage, or 
liquid extract of ergot 2-10 minims may be tried. 

Pyuria. — Pus present in the urine may come from any part of the 
urinary tract or from an appendicular, perinephritic, or spinal abscess opening 
into the bladder or urinary tract. The most common causes are pyelitis, 
tubercular kidney, calculus, and cystitis. 

Cystinuria. — Occasionally cystin may be found in considerable quanti- 
ties. The urine is opalescent when passed, and on examining the deposit 
after standing with a low power crystals of cystin will be seen. In a case of 
ours in a girl of 9 years attacks of abdominal pain and vomiting were 
followed by the appearance of cystin in the urine. 

Albuminuria in Apparently Healthy Children. — Albumen in more 
or less quantity is found in the urine of a considerable number of children and 
young adults, who have no definite symptoms of renal disease and who are 
in good health, or at any rate are not considered ill by their friends. The 
frequency with which this albuminuria is found during early life has been 
differently estimated by various observers. Thus, Ward (quoted by Dr. S. 
West) found on examining the urine of 126 children attending Dr. Garrod's 
out-patients at Great Ormond Street, that one-fourth (24*6 per cent.) con- 



Albuminuria in Apparently Healthy Children 595 

tained more or less albumen ; but in only 7-5 per cent, was the amount 
appreciable. The test used was boiling and the addition of acetic acid. 
Dr. Clement Dukes, as the result of his experience, concludes that at least 
22 per cent, of schoolboys (10-18 years) have albuminuria. Probably every 
physician who methodically examines the urine of his patients in order to 
feel that he is not overlooking early kidney disease will have been struck with 
the frequency with which he gets a cloudiness on boiling which does not 
disappear on adding acetic acid ; and this in patients or proposers for 
insurance who have no symptoms of Bright's disease. This is especially 
true in boys and girls of school age. It is not necessary for us here to 
discuss the significance of mere traces of albumen, or to decide the some- 
what difficult question as to whether the opalescence is due to serum 
albumen, nucleo-albumin, globulin, or some other proteid, though it is 
doubtless wise in those cases in which traces only are found to examine, if 
possible, other specimens passed at different times of the day and on 
different dates. The cases which are most perplexing and difficult are those 
in which considerable quantities of albumen are found in some specimens 
and no albumen or only traces in others. Such cases have been described 
as ' cyclic ' or ' intermittent ' albuminuria. They occur by no means infre- 
quently in boys and girls from 8-16 years, and are quite as common in our 
experience in girls as in boys. The urine passed on or before rising in the 
morning is free from albumen or nearly so, while specimens passed after 
breakfast or midday give perhaps a thick cloud on boiling, or it may be 
sufficient to deposit on standing \ to ^ of its volume of precipitated albumen. 
The amount varies during the day, and is again absent after a night's rest. 
The urine is usually of high specific gravity, 1025 to 1030, both when 
albuminous and also when free from albumen. No blood or casts are 
detected on microscopical examination. There is no puffiness nor oedema, 
and no cardiac hypertrophy. The patient appears quite well, and wonders 
why he is physicked, dieted, or put to bed. The albumen disappears when 
the patient is kept in bed on a fluid diet, but probably appears again when 
he gets up and about and goes back on ordinary diet. Dr. C. Dukes has 
described a similar class of case, but calling special attention to the fact that 
the intermittent albuminuria is very frequently associated with frontal 
headache, high tension pulse, and a tendency to faint. We can certainly 
confirm his observations from our experience. 

In connexion with these cases we must bear in mind that intermittent 
albuminuria is common in children recovering from scarlatinal nephritis and 
also diphtheria. We have often noticed in our fever ward that in children 
who have had oedema and albuminous urine and apparently recovered, the 
albumin has disappeared while they were kept in bed on a milk diet, but 
reappeared when they were allowed to get up and go about the ward. We 
have several times discovered 'intermittent 'albuminuria in children in families 
where one or more members have died young of Bright's disease. In all 
forms of Bright's disease the urine is apt to contain less albumen when the 
patient remains in bed than when he is up. 

What is the prognosis in these cases of albuminuria without definite 
symptoms of ill-health ? In the majority of instances they improve, and 
finally the albumen disappears in the course of months and years. In 

Q q 2 



596 Diseases of the Genito -urinary System 

another class, the patient remains for years in statu quo ; one of our cases 
has been more or less under observation for ten years, and is now eighteen 
\ cars of age, and still has albumen in his urine. In a third class, after 
awhile definite symptoms of Bright's disease, such as puffiness of the face 
and oedema, develop. This has been so in one or two cases which we know of. 

The prognosis in any case will be more serious in those who have at one 
time suffered from nephritis, and in those in which there is a family history 
of Bright's disease. 

The treatment of these cases presents the difficulty that the patients are 
not ill, that the course is chronic, and the friends are apt to think that an 
unnecessary fuss is being made. It is clear in such cases, however, that a 
guarded prognosis must be given, and every care taken, especially during 
the winter months, to guard against exposure to cold. Where there is 
evidence of the uric acid diathesis, alkalies, such as the effervescing citrate 
of potash, or phosphate of soda, should be given with an occasional dose of 
calomel. If there is any history of Bright's disease in the family, it is well, 
if possible, for the patient to winter abroad or in the south-west of England. 
Butcher's meat, in all its forms, should be interdicted, for a while at least. 



Diseases of the Kidney 

Congenital Anomalies of the Kidneys. — The principal malformations 
of the kidneys found post mortem are : (1) absence, or only a trace, of one 
kidney, with hypertrophy of the other ; (2) 'horse-shoe 'kidney, in which the 
two kidneys are united by a bridge of kidney tissue, giving the organs a horse- 
shoe shape. The kidney is placed with its convexity downwards, the ureters 
passing down behind the bridge. (3) The kidneys are frequently found 
lobulated, the surface being deeply fissured, or divided into 'lobules,' as in 
the foetal state. (4) Movable kidney. 

These abnormalities, though of extreme importance in reference to opera- 
tions on the kidneys and the diagnosis of abdominal tumours, need not be 
further referred to here. Obliteration of one ureter, partial or complete, may 
give rise to hydronephrosis and require operation, as in a case reported by 
Tuckwelland Symonds of Oxford. 1 Incontinence of urine from an abnormal 
opening of the ureter just in front of the meatus urinarius has also been 
met with. 2 

Displaced or Movable Kidney. — ' Floating kidneys ' are by no means 
rare in adults, especially in women ; they are not often discovered in infants 
and children. We have known several instances, but have not seen a well- 
marked case post mortem. Comby reports eighteen cases coming under his 
notice ; sixteen were in girls and two in boys. It is probable that this condi- 
tion is usually congenital, the attachment of the kidney is longer and looser 
than usual, and it is surrounded by peritoneum and attached by a mesentery. 

The right kidney is affected in the vast majority of cases. In fourteen 
of Comby's cases the movable kidney was associated with dyspepsia and 
dilatation of the stomach ; this association of movable kidney and dyspepsia 

1 Brit. Med. Jour. November 17, 1883. 

2 Archives for Pediatrics, November 1894. 



Displaced or Movable Kidney 597 

is common at all ages, and probably depends upon the close connection 
between the renal and solar plexuses. The same author speaks of 
paroxysmal pains in some cases, apparently from the kidney becoming 
twisted and the ureter occluded. In the majority of cases no symptoms are 
apparently produced and the movable kidney is discovered by accident. In 
palpating the kidney, the left hand should be placed in the lumbar region 
behind, while the right is pressed backwards from the front, an attempt 
being made to seize the kidney between the two hands ; its mobility can thus 
be tested. In some cases the kidney can be pushed upwards under the liver 
or downwards to the brim of the pelvis. A severe case might justify 
operation, otherwise the treatment is palliative. 

Tumours of the Kidneys. — Swellings occurring in the region of one 
of the kidneys may be due to one of the following causes : 

(1) New growth. (2) Tubercular or other abscess in the kidney. 
(3) Hydro-nephrosis. (4) Perinephritic abscess. 

(1) Renal New Growths. — In the majority of cases a new growth in- 
volving a kidney is a round-celled sarcoma which begins outside the kidney, 
gradually displacing and compressing the kidney itself. It is difficult to say 
exactly where these growths begin : presumably in lymphatic tissue. In the 
minority of cases the new growth appears to begin in the kidney itself — at 
least no trace of the kidney can be found post mortem, but traces-of kidney 
structure may be found scattered through the tumour on microscopical 
examination. 

In some cases the tumour is a myo-sarcoma, or in other words it is a 
round-celled sarcoma with a variable quantity of striated muscular tissue 
and spindle-shaped cells. In rare cases the growth consists of alveoli lined 
with columnar epithelium, similar in structure to the cylindrical epithelial 
carcinomas found in the large intestine. It is difficult to sayjwhere such 
tumours begin when occurring primarily in the kidney : possibly in the 
remains of the Wolffian body. Kelynack thinks that carcinomata ' probably 
never occur in children.' 

Renal sarcomata are usually soft in consistence, resembling brain sub- 
stance, and frequently contain masses of blood clot and altered blood in 
consequence of haemorrhages which take place into their substance. They 
often attain to great size, weighing many pounds, and by their enlargement dis- 
place the other organs of the abdominal cavity. The liver or spleen is pushed 
upwards, the small intestines are pushed on one side or backwards ; the 
large intestine, where it crosses the tumour, is compressed against the 
abdominal wall (see fig. 134). The tumour may set up a certain amount 
of chronic peritonitis and contract adhesions to the intestines and other viscera. 
Renal sarcomata occur most commonly in children under six years ; 
of fifty cases collected by Seibert, forty occurred during the first five years of 
life, twelve being in infants under a year old. In a case recorded by 
A. Jacobi a sarcoma was present in the kidney of a foetus born dead, and 
other cases (Sir William Roberts and Lloyd Roberts) have been recorded in 
which the tumours were present at birth. 

F. T. Paul, 1 of Liverpool, whose paper on this subject is one of the most 

1 Liverpool Med. -Chi?'. Jour. January 1894. 



598 



Diseases of the Genito- urinary System 



important of those recently published, says, ' The chief characteristics of i on- 
genital renal sarcomata are these : 

'(l) They show themselves during the first five years of life, and arc- 
probably invariably of congenital origin. 

' (2) They are primarily extra-renal though usually intracapsular.' 
He points out that they may be bilateral, that they cause death by ex- 
haustion or pressure rather than by urinary lesions, that metastatic growths 

only occasionally occur, but all forms 
of growth tend to recur after removal. 
The tumours frequently contain striped 
muscle, embryonic renal tissue, and 
various forms of adult connective 
tissue. The complexity of the struc- 
ture of these growths is to be explained 
by the inclusion within the capsule 
which forms round the embryonic 
kidney of elements of other neigh- 
bouring tissues. Mr. Paul describes 
growths of the 'simple connective 
tissue type,' of the ' complex connective 
tissue type,' and of the ' renal adenoma 
type. 5 

Kelynack (' Renal Growths ') says 
over 5 2 per cent, of malignant growths 
occurring at all ages were met with 
below ten years, and that most if not 
all of these were sarcomatous. 

Symptoms aiid Course. — In the 
majority of cases enlargement of the 
abdomen due to the new growth 
encroaching on the Other abdominal 
organs is the first symptom to call the 
attention of the friends to the case. In 
the minority of cases (one-fifth, Seibert) 
hematuria is the first symptom, occur- 
ring at a variable period before the 
discovery of a tumour. The swelling- 
is first noted occupying the right or 
left lumbar region, between the ribs 
and the crest of the ilium ; it has a 
rounded outline, which can be traced 
downwards, but not into the pelvis, and upwards behind the liver or spleen. 
By palpation it can be separated from the liver or spleen. It moves less 
freely with respiratory movements than an hepatic or splenic tumour does. 
Percussion shows that the large bowel lies across superficially to it, but if the 
tumour is large the colon may be compressed and no tympanitic note will 
then be detected. The swelling has a soft semi-fluctuating feel, and on 
exploration with a subcutaneous syringe pure blood is withdrawn. During 
the early stages the patient appears perfectly well, is well nourished. corn- 




Fig. 133.— Malignant Tumour of Kidney in a 
girl of nine years. Dr. Hutton's case. 



Renal New Growths 



599 



plains of no pain and there is no tenderness on handling the tumour. Ex- 
ceptionally pain is complained of ; in some cases it is acute and due to 
accompanying peritonitis. In Seibert's collection of fifty cases haematuria 
was present in nineteen at some time or other during the course. Vomiting 
is an occasional symptom. As the tumour increases in size it distends the 
abdominal walls, the skin becomes smooth and shiny, and is marked with 
large dilated veins. The tumour pushes up the diaphragm, passes perhaps 
beyond the middle line in front, and extends backward to the spine behind, 
sometimes, as in the case fig. 133, forming an enormous abdominal tumour. 
The liver and spleen are frequently enlarged ; the patient gradually 
emaciates and has a cachectic appearance ; perhaps the lower limbs become 
oedematous from pressure on the vena cava, and death comes after many 
weeks of lingering misery. Constipation is often present from pressure on 
the colon. 

Diagnosis. — A sarcomatous enlargement of the kidney may be possibly 
mistaken for a hydro-nephrosis, abscess of the kidney, perinephritic, or spinal 




Fig. 134. — Congenital Renal Sarcoma, from a photograph. 
(F. T. Paul.) 

or other abscess. It is less likely to be mistaken for a tumour of the liver 
or spleen. A renal tumour may be distinguished from an hepatic or splenic 
titwour by the fact that it moves less with respiration and the colon traverses 
its anterior surface, and moreover the edge of the liver and spleen may usually 
be felt. A congenital hydronephrosis, in which the obstruction in the ureter 
is complete, may cause some difficulty in diagnosis ; there would be, how- 
ever, in a swelling of any size, fluctuation transmitted from the abdomen to 
the flank in a hydro-nephrosis, and on exploratory puncture the fluid with- 
drawn would make the diagnosis clear. An abscess in, or scrofulous enlarge- 
ment of, the kidney is rare without a history of pain and tenderness in the 
lumbar region, and without pus in the urine. It is, however, possible that 
these may be absent, and then the rapid growth in the case of a sarcomatous 
kidney would in time decide the diagnosis. But a difficulty could rarely 
occur. 



600 Diseases of the Geuito-nrinary System 

Prognosis. — This is necessarily grave : though such tumours are chronic 
in their course and the patient may live for many months or even a year after 
the discovery of the tumour. 

Treatment. — As far as we know, no drug- influences the progress of the 
growth. Removal of a sarcomatous kidney is usually followed so rapidly by 
recurrence that this, the only possible, treatment is hardly justifiable unless 
the tumour is recognised in an early stage, when it is worth trying. Abbe 
has had one or two successful cases. 

Tuberculous Kidney. — Tuberculosis of the kidney is very commonly 
met with in children as part of a general tuberculosis. Thus of no fatal 
cases of tuberculosis in the Children's Hospital in the years 1881-1885 in- 
clusive, in forty-six there was evidence of tubercle in the kidneys in larger 
or smaller amount. Most frequently the lesions are simply scattered grey 
tubercles in the substance or on the cortex of the organ : this was the case 
in thirty-nine instances. 

Much more rarely large masses of tuberculous material are found, or 
occasionally extensive destruction of the papillae and ulceration of the pelvis, 
and sometimes of the ureter. Occasionally calculi are found co-existing with 
tuberculous lesions. 

It is rare in our experience to find children suffering from tuberculous 
kidney apart from a general tuberculosis ; less than half a dozen such cases 
were admitted to the hospital in the five years above mentioned, and genito- 
urinary tuberculosis — i.e. lesions affecting the kidneys, bladder, testes, pros- 
tate, vesiculas seminales — is not nearly so common as in adult life, though 
the bladder is not rarely involved. When the tuberculous lesions of the 
kidney are only part of a general tuberculosis, life is usually destroyed before 
the kidney affection is very far advanced, but where the disease is limited 
to the urinary tract the whole of one kidney may be destroyed and converted 
into a mere sac with hardly a trace of secreting structure left. Very com- 
monly both kidneys are affected together, but in a considerable proportion of 
cases one organ alone is attacked, and under such circumstances life may be 
prolonged, or even recovery may take place, the damaged kidney shrinking 
and ceasing to cause irritation ; the whole of the work then devolves upon 
its fellow. All stages of disease, from the presence of a few tubercles to that 
of cheesy masses, and on to complete disorganisation, may be found. Peri- 
nephritic abscesses develop in some cases. 

Symptoms. — When the kidneys are the seat of miliary tuberculosis there 
are usually no symptoms whatever pointing to disease of those organs : thus 
of thirty-nine cases of this form of disease, in only one was there even albu- 
minuria, and that to a very slight degree. When, however, tuberculous 
ulcers or abscesses exist, pus, mucus, and large quantities of albumen may 
be found ; but the only instance in which haematuria existed in the forty-six 
cases of tuberculous kidney we have examined was one in which calculi 
co-existed with the tubercle, and undoubtedly the presence of blood in the 
urine points to calculi rather than to renal tuberculosis. 

Pain and tenderness are only prominent symptoms when there is extensive 
disease and the pelvis becomes distended with pus and tuberculous material, 
and the same statement holds good of enlargement : it is only in the later 
stages of the disease that any palpable enlargement of the kidney takes place 



Tuberculous Kidney — Hydroneplirosis 60 1 

Frequent micturition is rather a symptom of tuberculous cystitis than of 
renal disease, and where it exists with evidence of tuberculosis of the kidney, 
especially if there is tenderness of the bladder and much pain on sounding 
or passing a catheter, it is tolerably certain that the bladder is affected as 
well as the kidney. 

The presence of tubercle bacilli in the urine would, of course, indicate 
urinary tuberculosis, thoug"h without other evidence it would not show 
whether the disease was renal or not ; unfortunately in most cases of renal 
tuberculosis the bacilli are not to be found until the disease is far advanced. 

When one kidney alone is affected and the ureter becomes blocked with 
caseous material or granulations, pyo-nephrosis may develop and form a 
large abdominal tumour in which fluctuation may be detected : in such 
cases more or less fever will also be present and the diagnosis will be easy. 
It is in the early stages that a doubt arises. If there is a tubercular 
history or evidence of tubercle elsewhere, if the trouble is of only a few 
months' duration and there is pus, but little or no blood in the urine, 
and if there is a gradual failure of health, the disease is probably renal 
tuberculosis. 

Treatment. — In cases of miliary tubercle nothing, of course, can be done 
for the renal affection. Where pyelitis exists medicine can do something : 
the urine should be kept unirritating by the use of diluents and boric acid 
(two- or three-grain doses in half an ounce of peppermint water) ; alkalies such 
as carbonate of potash or liquor potassae, or the citrate of potash with hyos- 
cyamus, will also be found useful. If there is lumbar pain and tenderness, with 
palpable enlargement of the kidney, and the symptoms do not subside under 
rnpdirir.al treatment, nephrotomy by the lumbar incision should be performed 
and the kidney drained. If on exploration the kidney is found entirely dis- 
organised, and there is evidence from the amount and quality of the urine that 
the other kidney is sound and efficient, a trial should be given to simple drain- 
age ; but, should the discharge not decrease, and should the health be failing, 
removal of the affected kidney is called for. This, however, clearly can only 
be justifiable if the other organ is working well, and if the bladder or 
viscera are affected nephrectomy would be probably useless. If removal of 
the kidney is decided upon, it should be done before the health is too much 
broken down, and the lumbar operation should be the one selected. We have 
only once met with a case in a child calling for either nephrotomy or nephrec- 
tomy, so that we do not think suitable cases can be common. 

Hydronephrosis is not very rarely met with in children, and may be 
congenital or the result of partial blocking of the ureter by a calculus or 
cicatrix. Complete obstruction of the ureter appears to lead usually to 
atrophy of the kidney rather than to hydronephrosis. 

The dilated kidney forms a tumour which has characters like those of 
the solid renal growths, except that fluctuation may be felt in it. The history 
is, however, often of longer duration than is the case in solid tumours, which 
usually prove fatal in less than eighteen months. Occasionally the fluid of a 
hydronephrosis is discharged by the ureter, in which 'case the swelling will, 
of course, vary in size. 

Treatment. — Hydronephrosis should be treated by incision, which is best 
performed in the lumbar region. The fluid which escapes has usually the 



602 Diseases of the Genito-urinary System 

characters of clear dilute urine. The kidney should be drained for some 
time, and only after failure of this treatment should nephrectomy be 
thought of. 

Renal Calculus. — Stone in the kidney is, like stone in the bladder, a dis- 
ease much more commonly met with in some localities than in others ; it is, 
how ever, apparently relatively rare in children, and when it does occur it is 
seldom that the symptoms are as severe or characteristic as they are in the 
case of adults. It appears that the majority of calculi formed in the kidney in 
children pass down to the bladder without giving rise to any severe symptoms 
of renal colic. Should, however, a stone form in the kidney and be retained 
there, it may give rise to pain, local and radiating, pyuria, frequent mictu- 
rition, tenderness on pressure over the kidney, with rigidity of the lumbar 
muscles, retraction of the testiSj vomiting, and above all to haematuria : this 
last is the most characteristic symptom of calculus, and in the absence of 
nephritis renal haematuria is probably due to calculus, though occasionally 
intermittent hematuria is met with without there being any proof of 
the presence of a stone. We have only on two or three occasions had 
to perform nephro-lithotomy in children. They recovered satisfactorily from 
the operation. 

In a few cases, if the disease goes on, pyo-nephrosis may be set up, and 
the kidney will then form a tumour perceptible to the touch. 

Treatment. — Should medicinal treatment, which is the same as that for 
tubercular nephritis, fail to give relief, the kidney should be exposed by the 
lumbar incision and explored by puncture with a needle ; if the calculus is 
struck, a director is passed along the needle, and the kidney opened along 
its convex surface and the calculus removed. If the needle fails to find the 
stone, the kidney should be carefully explored with the finger, both by 
palpation upon the surface and subsequently by opening the pelvis and 
examination with the finger and with sounds. Any calculus found should 
be removed and a drainage tube passed up to the surface of the kidney. 
The wound is then treated on ordinary principles, the tube being 
gradually shortened. If the kidney is healthy and the ureter patent, 
the wound will probably speedily close entirely ; if, however, the ureter 
is blocked, or there is much destruction of the kidney, discharge may go 
on indefinitely, and it may be necessary to remove the organ in order to 
obtain healing of the wound. Before nephrectomy is thought of, however, 
care must be taken to ascertain that the other kidney is capable of doing 
sufficient w r ork. For further particulars we must refer to the works of Morris, 
Bruce Clarke, and Newman ; also to papers by one of the present writers in 
the 'Medical Chronicle' for 1886-7-9-94. 

Acute pyelitis is certainly not a common disease in infants or children. 
We have, however, seen several cases of acute illness in infants or young 
children accompanied by a high temperature of an intermittent type, and 
after the attack has lasted several days it has been noted that the urine 
contained pus ; the nurse having called attention to the fact that there 
was something unusual in the way in which the urine stained the diapers. 
Dr. S. J. Gee has recorded a similar case in an infant of nine months. 
Dr. Emmett Holt records three such cases in infants of eight months, nine 
months, and fourteen months respectively. The temperature in one of his 



Renal Calculus — Acute Nephritis 603 

cases ran high, and there were distinct ' chills ' in which the infant became 
blue. 

What is the exact nature of these cases, and whether the pyelitis is 
primary or secondary to some other disease, it is difficult to say. All the 
recorded cases ended in recovery. 

Acute Nephritis. — Acute inflammation of the kidneys occurs much less 
frequently as a primary than as a secondary disease. The kidneys are 
fortunately not so prone to take on inflammation as the lungs, possibly 
because they are less exposed to cold and they are out of reach of the 
micro-organisms present in the air. 

Acute nephritis does, however, occur as a primary disease, or at any rate 
in patients who, as far as can be ascertained, have not suffered from any ante- 
cedent disease, and who were in perfect health up to the time of the attack. 
Thus we find a schoolboy, who has never had scarlet fever and been in good 
health, have a shivering fit, an evening rise of temperature, followed by the 
passage of albuminous and perhaps dark urine, and pass through the stages 
of a typical attack of acute nephritis. In other cases the onset is more 
insidious, and the first thing noticed is a pale and puffy face. But in all cases 
in which the urine contains blood as well as albumen and casts, we should 
be suspicious of antecedent scarlet fever, though possibly a very mild attack. 
In rare cases acute nephritis occurs during infancy apparently as a primary 
disease ; and it is needless to say that it may be readily overlooked, as the 
urine of infants is not often examined unless special attention is called to it 
on account of its staining the napkin. If there is associated broncho-pneu- 
monia or gastro-intestinal disturbance, it is still more likely to be overlooked. 
The difficulty of diagnosis in such cases is not always overcome by a post- 
mortem examination, inasmuch as we may find pale kidneys with more or 
less marked parenchymatous changes in infants who have died of enteritis, 
septic pneumonia, and other acute diseases. It is by no means easy always 
to say, when sections of kidney are examined microscopically, whether such 
changes as desquamation of the epithelium are pathological or accidental, or 
whether there is slight proliferation of the epithelium or not. 

Reference has already been made to acute nephritis (p. 257) when speak- 
ing of scarlet fever, as acute nephritis occurs more frequently during con- 
valescence from this fever than after any other disease. It is well to bear in 
mind, however, that nephritis may occur after some other febrile states, such 
as diphtheria, croupous pneumonia, varicella, typhoid fever, vaccinia, and 
eczema. These febrile conditions appear to give rise to an irritable state of 
the kidneys and render them liable to take on an acute inflammatory state. 
It must not be forgotten that nephritis may follow mild attacks of scarlet 
fever ; the primary fever may have been overlooked by the friends, especially 
if the latter are unobservant or ignorant ; and in any patient coming under 
notice for the first time, suffering from acute nephritis, the history of the case 
should be carefully inquired into and the child's skin examined for any traces 
of desquamation. 

In the following case acute nephritis supervened during an attack of 
croupous pneumonia. 

Croupous Pneumonia, Acute Nephritis. — George H., aged 4 years. 
March 18 was sick and feverish ; admitted March 20. There was well- 



604 Diseases of the Genito-urinary System 

marked dulne.ss and bronchial breathing at the left apex, both in front and 
behind. P. ioo ; R. 60; T. 103 ; urine ^th albumen. March 21. — T. 104 , 
much dyspnoea ; only 8 oz. of urine passed, which contains much blood and 
albumen. March 24, only 1 oz. of urine passed in last twenty-four hours, much 
blood and albumen. Vomiting. T. 104 . After this date he improved, the 
temperature fell April 4, and recovery ensued. 

Acute nephritis occurring during convalescence from scarlet fever, or as a 
primary disease, is usually an inflammatory lesion of the croupous pneumonia 
type. There is an inflammatory engorgement of the blood vessels with fever 
of an intermittent type, and, as a result, a choking of the tubules by the 
exudation of liquor sanguinis, and usually of blood corpuscles. As a conse- 
quence of this the urine is scanty and contains fibrinous casts, blood corpus- 
cles, albumen, and much epithelial debris. In the less acute cases there is 
not sufficient blood present to discolour the urine. If the inflammatory 
condition fails to be relieved, secondary changes occur, the most important 
of which consists in a glomerular or periglomerular nephritis. The glomeruli 
become enlarged in consequence of a hyperplasia of their endothelial nuclei 
(Friedlander), or in other cases a fibro-cellular growth takes place between 
the glomerulus and the capsule of Bowman ; in either case the result is the 
same — namely, an obstruction to the flow of blood through the glomerulus. 
Changes in the epithelium also take place. As these changes progress the 
urine becomes more and more scanty, and death takes place from either 
cardiac failure, uraemia, or some inflammation of a serous membrane. 

The symptoms and treatment have already been discussed (pp. 258 and 
265), and little need be added here. It is well to bear in mind that cases of 
very different severity may fye met with : in some cases the engorgement of 
the kidney is extreme, and variable quantities of urine are passed, containing 
large quantities of blood and albumen. In other cases there may be marked 
anaemia, much general oedema, scanty urine, with no albumen or only a trace, 
and we may be left in doubt if the case is really one of nephritis or whether 
the oedema is simply due to a watery state of the blood. This class of case 
is not uncommon in young children under three years who have recently 
suffered from some acute disease, such as acute diarrhoea or pneumonia ; the 
pallor and oedema present suggest acute nephritis, but an examination of 
the urine possibly gives negative results as far as albumen is concerned. 
In some of these cases we have failed to find any evidence of nephritis on a 
microscopical examination of the kidneys. Acute or subacute attacks of 
nephritis do, however, occur in young children. The first symptom is mostly 
oedema of the face, the oedema becoming general. It is often associated 
with broncho-pneumonia, and tends to a fatal issue. 

Septic Nephritis has been also referred to under the complications of 
scarlet fever (p. 258). It is well, however, to bear in mind that such cases 
occur after other febrile states. We have seen a condition of the kidneys 
answering this description occurring apparently primarily, but we have always 
had our suspicions that some cause must have been overlooked. 

Acute Toxic Nephritis, Parenchymatous Nephritis. — In diphtheria, 
malignant endocarditis, zymotic diarrhoea, and any disease in which there is 
ptomaine poisoning, there is albuminuria, and certain changes in the kidney 
are found after death. This is specially so in diphtheria. We have already 



Acute Toxic NepJiritis — Chronic Nephritis 605 

referred to the albuminuria which so frequently occurs in the course of this 
disease, and also to the fact that in some cases, especially in the malignant 
ones, the urine becomes more and more loaded with albumen while becoming 
more scanty, and complete anuria may take place twenty-four hours or forty- 
eight hours before death. Unlike scarlatinal nephritis there is rarely oedema, 
muscular twitchings, or uraemic convulsions, but coma usually precedes death. 
On post-mortem examination of the kidneys of those dying from diphtheria, in 
most cases the kidneys will be found to be hyperasmic and slightly enlarged, 
the cortex being pale, the medullary portions congested. The principal 
microscopical changes occur in the epithelial cells, which are swollen and 
granular. A few fibrin cylinders and blood cylinders are sometimes present. 
No very marked changes sufficient to account for complete anuria have been 
found in the kidneys of those dying with total suppression of urine. It is 
possible, as has been suggested, that the anuria is due to a peripheral neuritis 
of the abdominal sympathetic, or that portion of the system which regulates 
the local tension of blood in the capillaries of the kidneys. 

Chronic Nephritis. — We cannot too strongly emphasise the necessity 
of examining the urine from time to time of children who have recently had 
scarlet fever, especially if they have suffered from scarlatinal nephritis. It 
is not enough to find that on one or two occasions the urine is free from 
albumen in order to declare them well. Nephritis, however mild, renders 
the kidneys liable to attacks, and these subsequent attacks may readily pass 
into a chronic nephritis in which organic changes take place and irretrievable 
damage is done. There may be an albuminuria which is intermittent, and 
in consequence a slight kidney affection is liable to be overlooked. We 
have already referred to cases in children who have suffered from nephritis 
and who were apparently quite well pass urine free from albumen during the 
night or when they were kept in bed, but albumen at once appeared in the 
urine when they got up, and especially if they went out of doors. In such 
cases an acute attack is readily set up, with attendant anaemia and dropsy. 
The history of a chronic nephritis is the history of a series of acute or 
subacute attacks, followed by a period of apparent health perhaps extending 
over many years. No doubt in a certain proportion of cases recovery even- 
tually takes place, but in others the kidneys become hopelessly damaged by 
fatty and fibroid changes, and they eventually succumb. In many of these 
cases the progress is exceedingly insidious ; it is only when the friends have 
their attention called to the puffy face or oedema of the feet that medical 
advice is obtained. 

In some instances we have known schoolboys who had apparently been 
in good health noticed by their house master to look ' puffy ' in the face, 
and on medical examination large quantities of albumen are found in the 
urine. There has been no history of scarlet fever and no marked symptoms 
till the oedema has been noticed. In these insidious cases of subacute 
nephritis the prognosis is mostly bad ; there is a course perhaps of three 
months to two years, but rarely complete restoration to health. 

In a typical case of subacute or chronic nephritis the appearance of the 
patient at once establishes the diagnosis — the bloated, puffy, pallid face is 
characteristic. The abdomen is distended, being tympanitic over the air- 
containing intestines and stomach, dull and fluctuating in the flanks from 



6o6 Diseases of tJie Genito-urinary System 

the presence of fluid. The scrotum is cedematous, the skin everywhere pits 
on pressure, especially on the dorsum of the feet. There is frequently 
headache and vomiting or nausea. The pulse is usually slow and of high 
tension, but in children the high-tension pulse of Bright's disease is less 
marked than in adults. The heart cavities become dilated, the apex beat is 
diffused and tends to become displaced outwards beyond the left nipple 
line. Possibly the urine is scanty, contains many casts, and is loaded with 
albumen. Gradual improvement takes place till the patient is fairly well 
again, and the urine free, or nearly free, from albumen. In other cases they 
remain for months in practically the same condition, the amount of albumen 
and dropsy varying from time to time. Gradually perhaps there is increasing 
dropsy, so that the patient becomes waterlogged. The face, lower extremi- 
ties, and scrotum are extremely cedematous, and the peritoneal cavity 
distended with fluid, while the sickness is very distressing. Dyspnoea is 
usually a marked symptom, and the patient has to be propped up in bed. 
Finally the patient lapses into coma, which marks the beginning of the 
end. The urine is often reduced in amount to one or two ounces in twenty- 
four hours. Urarmic convulsions are common at 'the last. 

In such cases a 'large white kidney' is found post mortem; sometimes 
the kidneys are enormously enlarged. In one of our cases (a girl of twelve 
years) the two kidneys weighed together 22§ ounces, and one measured six 
inches in length. Such kidneys show the epithelium infiltrated with fatty 
drops, and various fibroid changes, especially around the glomeruli, many 
of the glomeruli having been strangulated by a surrounding fibroid growth. 
The heart is hypertrophied. 

The ' granular contracted kidney ' is rare in children • we have seen 
at least five cases — three occurred in girls, aged n^ years, 10^ years, and 
7 years respectively— and two in boys aged 12 years and 4 years 11 months. 
In the first case there was only a history of two or three weeks' illness 
before admission to hospital, but the history was imperfect ; she had never 
had scarlet fever ; when admitted there was much oedema and dyspnoea ; the 
urine was of sp. gr. 1015, containing half albumen — she passed 800-1000 c.c. 
daily. At the post-mortem the right kidney weighed i\ oz. and the left | oz. 
The left was a mere vestige of a kidney ; the capsule of the right was ad- 
herent, the surface granular, the cortex was narrow, and, in short, the kidney 
was an extreme example of a granular contracted one. The ureters were 
dilated. The heart weighed 8 oz., the walls of the left ventricle were much 
hypertrophied. 

A second case (girl 10^ years) was admitted to a surgical ward for 
rickety deformity of the tibia. There was a history for two years before 
of thirst, headaches, and frequent passage of urine, especially at night. On 
admission there was urgent dyspnoea, for which no cause could be found ; 
she gradually passed into an unconscious state, and died twenty-four hours 
after admission. No urine was obtained, she having passed it into bed. 
At the post-mortem the kidneys were typically granular and contracted ; 
they together weighed 1^ oz. only, and measured two inches in length ; the 
capsules were adherent, the surface granular, and the cortex surface wasted ; 
the heart weighed 8| oz. and the left ventricular walls were thickened. 

In the third case, that of a boy aged 12 years, it was uncertain if he 



Chronic NepJiritis — Addison's Disease 6pj 

had had scarlet fever ; he had measles at three years of age which had left 
him deaf in one ear. For three months before death he had suffered from 
frontal headaches and had been thirsty. A month before death he had 
uraemic convulsions, which continued at intervals. Only one or two specimens 
of urine were obtained; the excretion was free, S.G. ioio, much albumen. 
Coma supervened twenty-four hours before death. There never was any 
oedema. Post-mortem: typical granular kidneys weighing \\ oz. each ; heart 
8 oz., hypertrophy of the left ventricle, thickening of the mitral valves, 
atheroma of the aorta and thickening of the aortic valves. 

A fourth case, a boy aged 4 years 1 1 months was admitted to hospital 
for genu valgum. No albumen was found in the urine. He was operated 
on, and a day or two after the operation he became drowsy. There was no 
fever, convulsion, or twitching ; he died comatose eight days after operation. 
There was albumen in his urine shortly before death. At the post-mortem 
made by Mr. Woodhouse, the kidneys were found small and shrivelled, 
weighing together 2 oz., the capsule was adherent, the surface irregular, not 
granular and pale. On section, the cortex was pale and much wasted, the 
calyces of the pelvis much dilated. The kidneys were undoubtedly wasted 
and shrivelled, but not typically granular. 

In another case (patient of Drs. Fawsitt and Godson), a girl of 7 years 
old was never strong from her birth and had more or less incontinence of 
urine all her life. For a year before death she was anaemic and easily out 
of breath on exertion. When seen some months before her death there was 
y 1 ^ albumen (by vol.), the cardiac area was enlarged towards the left, but the 
apex beat was just inside the nipple line. There was a bruit heard at apex 
and base. The spleen was enlarged. The anaemia increased and oedema 
supervened. At the autopsy small white granular kidneys were found ; the 
larger of the two, which Dr. Godson kindly forwarded to us, weighed f oz. ; 
the left ventricular wall was hypertrophied, the cavity not dilated. 

Treatme?it. — In chronic albuminuria the patient must be rigidly pro- 
tected from cold, as the least chill is liable to lead to an acute attack. Bed 
is the best place as long as albumen is present in the urine. A simple un- 
stimulating diet is necessary, milk forming the staple food, with arrowroot, 
ground rice, or other light puddings. Meat is best avoided as long as the 
urine is albuminous. When oedema is present and the urine scanty, hot 
air or vapour baths should be given daily, while the kidneys are acted on 
by salines, such as tartrate of potash, diuretics, digitalis, or squills. During 
convalescence tr. ferri acetatis may be given with digitalis. Vomiting is 
best treated by saline purgatives and peptonised milk gruel in small quantities. 
Nitro-pilocarpine in ^ gr. doses by the mouth seems often to relieve. In 
anaemic convulsions injections of morphia, T ^-£ gr., are useful and may be 
given without risk (see also F. 91, 92, 93, and 94). 

Addison's Disease. Tuberculosis of the Adrenals. — Addison's 
disease occurs occasionally in children after puberty ; it is very rare before 
this epoch. Dr. Pye Smith has recorded a case in a boy of fourteen years, 
and Monti has collected eleven cases in children from three to fourteen years 
of age. Tubercules, both caseous and grey, are frequently present in the 
suprarenal capsules of children dying from general tuberculosis, without 
any symptoms occurring during life. 



608 Diseases of tlie Genito-urinary System 

Dr. J. S. Bury has recorded a well-marked case in a girl of thirteen years 
of age. The early symptoms were those of gastric disturbance and vomiting, 
which continued throughout her illness, which lasted twelve months. Her 
skin gradually became discoloured, all the parts of the body being of a 
brown colour. She gradually wasted and died of exhaustion. The adrenals 
were found adherent to the fatty tissue which surrounds them and to the 
diaphragm ; on section they showed caseous and fibroid changes. There 
was no tuberculosis elsewhere. 



609 



CHAPTER XXVIII 

DISEASES OF THE GENITOURINARY SYSTEM — continued 

Stone in the Bladder in children is, as in adults, a much more common 
disease in some localities than in others. It may occur at any age, and a 
congenital case even has been recorded. The symptoms vary much in 
severity ; sometimes but little pain or trouble is caused by the stone, at other 
times the distress is constant and severe. The causation of calculus need 
not be discussed : there is little evidence that any particular diet has any 
active share in producing it. 

Symptoms. — There is usually pain referred to the end of the penis, or to 
the hypogastrium or perinaeum ; the pain is most severe towards the end of 
micturition, but when there is cystitis it is nearly constant. Passage of blood 
in the urine, usually at the end of micturition, is a very frequent though not 
absolutely constant sign ; frequent micturition and inability to retain the 
urine are almost always present. The straining efforts to empty the bladder 
often give rise to prolapse of the rectum and hernia. An elongated, ex- 
coriated prepuce, the joint result of the irritating quality of the urine, of 
frequent micturition, and of pulling at the penis to relieve the irritation felt at 
the end of the organ, is usually seen. The urine is muddy, containing pus and 
phosphates in varying quantity ; if no cystitis is present, it may, however, be 
quite clear. On sounding, the stone is usually felt at once ; it is rare to find a 
stone in children that is not struck by the instrument as it enters the bladder, 
but, as this is not always so, if the other signs of stone are present, repeated 
soundings should be made if the calculus is not found at once. 

E. Owen suggests that sometimes the stone may be lodged in the orifice 
of one ureter : but, though Dr. Cullingworth and others have recorded such 
cases in adults, we do not know of an instance of this in childhood. 

The most common variety of calculus in children is the uric acid ; next 
perhaps, comes the form consisting of urates ; if the stone has caused cystitis, 
there may of course be a phosphatic coating, or the whole calculus may be 
phosphatic. Ebstein believes that the uric acid infarcts of newly born 
children form the first stage in calculus production, and that the large 
quantity of uric acid present in fcetal and early life explains the frequency of 
calculi of this substance (' Centralblatt f. Chirurg.' No. 14, 1885). The 
abnormal elimination of uric acid leads to degeneration of epithelium, which 
forms the animal basis of the calculus. 

Calculi in children vary much in size : that is to say, that as different 
calculi give rise to varying degrees of distress, some of them are allowed 

R R 



6io Diseases of the Genito-urinary System 

to reach a larger size before the child is brought for treatment than are 
others. 

In shape the calculi are usually oval and flattened (uric acid), but spindle- 
shaped stones are often met with : such are those which, while small, so 
frequently pass into the urethra, and, becoming impacted, give rise to re- 
tention of urine. Thus one of these small oat-shaped calculi some day comes 
to lie with one end projecting into the urethra, violent straining to pass urine 
takes place, and the calculus is washed along the urethra and usually becomes 
fixed just within the meatus at the fossa naviculars, since the meatus is the 
narrowest part of the urethra. In other cases the stone is arrested at the bulb 
or in the penile portion of the tube. The symptoms of such an occurrence are 
pain, oedema of the part, retention of urine, and tenesmus ; on examination 
the stone can usually be felt through the urethral wall, or is readily struck on 
passing a sound or probe into the urethra. If the case is neglected, ulcera- 
tion may take place and extravasation of urine : this sometimes occurs very 
rapidly. We have seen fatal extravasation come on in a few hours. When 
this occurs the symptoms are the same as in an adult : pain, swelling of the 
perinaeum, scrotum, and penis, constitutional disturbance, and, failing relief, 
rapid sloughing of the tissues. In all cases of retention of urine in a child, if 
phimosis will not account for the inability to empty the bladder, impacted 
calculus should be suspected. The secondary effects of calculus are cystitis, 
pyelitis, and suppurative nephritis. The ureters may become dilated and 
inflamed by extension of mischief from the bladder ; and obstruction to the 
outflow of urine, suppurative pyelitis, and subsequent extension of suppura- 
tion along the renal tubes and in the peritubular tissue may result. This is 
probably not always fatal, and on removal of the stone the kidney mischief 
may subside : nevertheless the injury so done to the kidneys may be one of 
the reasons why children, the subjects of stone, seldom seem to grow up, 
though the mortality from lithotomy is so small in childhood ; it is, as 
Mr. Erich sen says, very rare to see an adult who has been cut for stone in 
childhood. 

Diagnosis. —One or more of the symptoms of stone may be caused by 
many other conditions : worms, phimosis, a contracted meatus urinarius, 
simple or tubercular cystitis, the so-called irritable bladder, 1 vesical tumours, 
and renal calculus, all may simulate stone in the bladder to a certain extent ; 
the diagnosis is only to be certainly made by sounding. Stones can often 
be felt by bimanual palpation, one finger being passed into the rectum and 
the other hand pressed down above the pubes. 

Treatme?it. — Until recent times lateral lithotomy has been practically 
always the mode adopted for removal of a vesical calculus in boys, and its 
success is so great that but little attempt has until lately been made to find 
any other treatment. Median lithotomy is little applicable, on account of 
the small size of the parts. Of late the operations of litholapaxy and supra- 
pubic lithotomy have both been employed in children. Keegan, in the 
'Indian Medical Gazette,' May 1884 {vide also ' Lancet,' vol. ii. 1886 and 
1890), 2 collected over one hundred cases of lithotrity in children between 

1 Thus, for instance, hematuria may result from phimosis and consequent irritable 
bladder (Bryant), and also may be due to tuberculous cystitis. See also p. 194. 

2 Also Southam, Med. Chron. vol. xii. 1890. 



Stone in the Bladder 6 1 1 

the ages of one and a half and eleven years ; among these there were three 
deaths ; in six cases the stone was allowed to escape with the urine after 
crushing, in the rest it was evacuated ; the size of the calculi varied from five 
grains to four drams. The operation has since been largely used. 

It is now well established, chiefly by the work of Keegan and Freyer in 
India, that the urethra of a child of three or four years will readily admit a 
No. 8 lithotrite after slitting the meatus, and we have found no difficulty 
whatever, as far as this goes, in the cases in which we have tried it ; such 
an instrument is abundantly powerful for the vast majority of stones we 
find in children, and there seems no valid reason against lithotrity on this 
ground. In one of our cases, however, the lithotrite broke in the child's 
bladder, and was removed, together with the stone, by suprapubic lithotomy. 
This child died of bronchitis shortly after. The death was clearly the result 
of the somewhat prolonged operation and exposure. Freyer even says that 
a No. 6 cannula maybe readily passed into a child under one year old, though 
this is not always the case. In our own cases there was some difficulty in 
seizing the stone, but this was got over in one case by passing a finger into 
the rectum and lifting the stone between the blades of the lithotrite. The 
operation, in this instance, was followed by pyaemia, and the child died ; 
after pyaemia had developed it was found that a second stone existed, and 
this, being lodged in the neck of the bladder, was removed by median litho- 
tomy, but the pyaemia was in no way improved. We do not, however, look 
upon this case as any argument against lithotrity, though it must be remem- 
bered that the natives of India bear surgical operations far better than 
Europeans, provided no bone lesion is present. In our case kidneys and 
ureters were both diseased, and probably this condition largely contributed 
to the fatal result. Though the cases we have mentioned show that litho- 
trity in children is not without its difficulties and dangers, we have no doubt 
from our own experience that it is the proper operation to perform in cases 
where the stone is small or of moderate size, and the child is not too weakly 
to bear an often necessarily prolonged manipulation. In any case a well- 
fenestrated lithotrite is essential, as detritus is apt to become jammed in 
the blades, and thus to prevent the withdrawal of the instrument without 
difficulty. We have had to open the urethra and protrude and clear the 
lithotrite before it could be withdrawn through the front part of the passage. 

As to the suprapubic operation, there is much to be said both for and 
against it. Against it is the risk of wounding the peritoneum, the risk of 
urinary infiltration, and the fact of the good results following the lateral 
operation. In favour of it is the fact that the operation is done as it were in 
the open : there is no cutting in the dark, no risk of wounding important 
structures such as the rectum, pelvic fascia, and seminal ducts, 1 while injury 
to the peritoneum is only likely to occur exceptionally, and is less likely in 
children than in adults, from the fact that in children the bladder is an 
abdominal, in adults a pelvic organ. 

Suprapubic lithotomy in children has, as shown by Sir Wm. MacCormac 
and others, a very small mortality ; it is an easy operation, and requires no 

1 Sir Wm. MacCormac quotes Haemstadt, to the effect that of eighteen males who had 
been lithotomised in childhood, and had grown up and married, only one had children. — 
Lancet, March 19, 1887. 

R R 2 



612 Diseases of the Genito-urinary System 

skilled assistance. In performing the operation no rectal bag should be 
used ; the bladder should be injected with from 3 to 4 oz. of boric lotion 
and a gradual dissection made down to the organ, not using the knife after 
the perivesical fat is exposed. A staff should be kept in the bladder during 
the operation, and its end used as a guide upon which to open the bladder ; 
by pushing the bladder up gently with the staff, and opening the viscus lower 
down, all risk of injury to the peritoneum is entirely avoided. As soon as 
the bladder is laid bare, two sutures are passed through it, and the organ is 
opened between them, the stone is extracted with forceps or the finger, and 
the wound either~]left altogether open or the bladder stitched up, the super- 
ficial structures being left quite open. Any stitches passed through the 
bladder walls should not include the mucous membrane. It is well to keep 
the child on its side or face after the operation, to allow free drainage away 
of any urine that may collect in the wound. In several cases (R. W. Parker 
and others) the wound has united by first intention, but, on the whole, we 
think it better to leave the rest of the wound open while the bladder wound 
is sutured, or perhaps better still to use no sutures at all. The operation 
has largely replaced lateral lithotomy, but further experience is required. 
We have not done lateral lithotomy for several years, all cases of stone 
having been dealt with either by lithotrity or the suprapubic operation. 

It is unnecessary here to describe the operation of lateral lithotomy ; it 
will be sufficient to point out that the operation in children differs from that 
in adults chiefly in that in childhood the field of operation is smaller, not 
only on account of the size of the patient, but because the genital organs are 
undeveloped and the prostate exists only in a very rudimentary condition. 
It is usually said that in children the difficulty of the operation is in getting 
into the bladder, in adults it is in getting the stone out. This arises partly 
from the small size of the parts already mentioned, partly from the fact that 
the bladder in children is more an abdominal than a pelvic organ, and partly 
because the tissues of the child are more easily lacerated than those of the 
adult, and very gentle manipulation is therefore required. In lateral lithotomy 
in a child the incision is usually carried through the whole depth of the pros- 
tate, instead of only through a part of the gland, and unless the opening 
into the bladder is fairly free there is a risk of pushing the bladder before 
the finger and stripping it up from its attachments, or even of tearing across 
the urethra. The only other point requiring remark is that in children it is 
often easy by passing a finger into the rectum to bring the stone within the 
grasp of the forceps, or even to extrude it from the perinaeal opening, and 
this is still further facilitated in some instances by pressure with the hand on 
the abdomen. In one case we could easily grasp the stones (there were two) 
with the hand through the soft, flaccid, abdominal walls. 

Vesical calculus is occasionally found in female children : in such cases 
the urethra should be rapidly dilated with a three-bladed dilator or a pair 
of dressing forceps, and the stone extracted. If the calculus is large, it 
should be crushed before extraction and the bladder well washed out. Rapid 
dilatation is not, as a rule, followed by incontinence, even temporarily ; in a 
case of our own the urethra of a child three years old was dilated sufficiently 
to admit the little finger, and there was no incontinence, even immediately 
after the operation. 



Cystitis 6 1 3 

The mortality after lithotomy in children is usually about 5 per cent. 
Death when it occurs is due either to exhaustion of the child by distress and 
pain before the operation, to kidney disease, or in some cases to peritonitis, 
cellulitis, septicaemia, or haemorrhage. 

Cystitis. — Though cystitis in children is very commonly due to stone, it 
is by no means rare to find other causes for it ; thus retention from phimosis, 
or a contracted meatus, or possibly a growth, may give rise to it : tubercu- 
losis of the bladder often is a cause of severe cystitis with much pain and 
haematuria, while frequent micturition with phosphatic deposit often occurs in 
children from such causes as errors of diet, or from no obvious reason. Rectal 
irritation may give rise to frequent micturition and even to haematuria. 

The so-called ' irritable rugous bladder' is a condition often described as 
a disease ; there is no doubt that certain children are brought with symptoms 
pointing to stone, and on sounding them no stone is found, but the bladder 
feels rough and traversed by ridges. We are, however, inclined to think 
this is not a pathological condition in itself, but simply the result of some 
passing irritation such as hyperacid or phosphatic urine, since these cases 
seldom require prolonged treatment and usually rapidly lose their symptoms 
after a course of salines followed by tonics. In Mr. Holmes's view it is 
simply a contracted bladder resulting from some irritation. Renal calculus 
and phimosis sometimes are the cause of this condition. 

Tumours of the bladder are rare in children ; one case of prostatic tumour 
has been already mentioned, and Owen records a case of his own, and 
mentions Giraldes' and Birkett's cases. Shattock has also recorded a case 
of mucous polypus in the 'British Medical Journal,' 1883, page 15, and 
several cases of sarcoma have also been met with {vide Southam) ; indeed 
sarcoma of the bladder occurs more frequently in childhood than any other 
form of growth. 

Tuberculous cystitis may be recognised, in the absence of stone or other 
obvious cause, by pain in urination, itching at the end of the penis, pain in 
the hypogastrium and perinaeum, frequent micturition, and sometimes incon- 
tinence. The pain may be greatly lessened by passing urine as soon as the 
least inclination to do so is felt ; the urine is alkaline, with a deposit of pus 
and stringy mucus and epithelium ; sometimes there is haematuria, and the 
bladder usually very readily bleeds — for instance, after gentle sounding. We 
have found a chain of enlarged lymphatics on rectal examination in a case 
of this sort, and also swelling, probably glandular, in the iliac fossa. Pres- 
sure over the bladder sometimes relieves pain. We have not found tuber- 
culous cystitis in children associated with genito-urinary tuberculosis, as is so 
commonly the case in adults, but the disease is not common enough to speak 
with authority. Terrillon says the deposit is less gelatinous and more floc- 
culent, and the pain more constant in tffberculous than in simple cystitis, 
while bleeding is an early symptom. Where the bladder alone is involved 
no casts will be found in the urine ; their presence would of course point to 
renal mischief. Ulceration takes place after a time, and the ulcers may be 
single and small, or numerous and large ; they are usually at the trigone. 

Treatment. — Alkalies, citrate of potash, and boric acid are the remedies 
most useful as given internally, opium and henbane being added where 
much pain is present. Washing out the bladder with boric acid (gr. x to 



614 Diseases of the Genito-urinary System 

3 i) is of much value in simple, but sometimes too painful in tuberculous 
cystitis. Powdered iodoform washed into the bladder forms a coating" upon 
its surface, and gives much relief in some cases ; it appears, however, to be 
somewhat specially prone to cause iodoform poisoning : this method was, 
we believe, first used by Mr. Whitehead for malignant disease. Rawdon 
suggests cystotomy in cases of tuberculosis where the symptoms are intract- 
able, and suprapubic cystotomy with subsequent scraping of the ulcer has 
been done in some instances. 

Incontinence of Urine. — During the first few months of life the infant 
has no voluntary control over the sphincters of the bladder ; urination at this 
time is a reflex act, like the respiratory movements or deglutition. During the 
last few months of the first year, a good nurse will have trained the infant to 
retain its urine till held over the chamber vessel, so that by the end of the 
first year the napkin can be dispensed with during the daytime. Before 
the end of the second year accidents either by night or day ought to be 
infrequent. Unduly frequent micturition may be due to mere habit, to a 
too often occurring desire to pass urine, or to an absolute inability to retain 
it. In the former the apparatus is perfect, but is by some cause or other too 
often excited ; in the last there is either paralysis or a malformation. 
Nocturnal incontinence belongs to the former group ; diurnal or continuous 
incontinence may be due to either condition. Thus a child may have a 
frequent desire to pass water because a larger amount is secreted, as in ' 
diabetes insipidus ; because it has a congenitally small bladder; because it 
has a stone or hyperacid urine, or cystitis, or a feeling of irritation about the 
penis from an adherent or tight prepuce or a contracted meatus ; or because 
worms or other rectal irritation are present. In all these conditions, except 
that of too small a bladder, the urinary apparatus may be quite perfect, 
but it is irritated. 

On the other hand, there may be continuous dribbling of urine from the 
bladder, as a result of distension and overflow from obstruction ; or in case 
of entire absence of the bladder, or extroversion, or imperfect development 
of the neck of the bladder or of the urethral muscles ; or, again, from 
deficient innervation, as in paraplegia, or from imperfection of the micturition 
centre in the spinal cord, as seen in some cases of spina bifida. Mention 
must also be made of certain rare conditions, such as an abnormal communica- 
tion between the bladder or ureters and the exterior. Obviously a child 
that can hold its water during the day can have none of these conditions ; 
hence, when a child is brought and said to be unable to hold its water, the 
first question is whether the condition is nocturnal only or constant. 
Dribbling from over-distension due to obstruction is nearly always the 
result of either an impacted urethral calculus or of phimosis, less often of a 
contracted meatus, though, of course, in these there is, as a rule, complete, 
or almost complete, retention rather than overflow. 

Inability to retain the urine is occasionally seen associated with hypo- 
spadias and incontinence of faeces : in such cases the condition is no doubt 
due to actual malformation of the sphincters. 

Dribbling from paraplegia will be recognised by the associated paralyses ; 
so too with the case of spina bifida : hence examination of the spine should 
be made in all cases, and the child's cerebral condition should also be 



Incontinence of Urine 615 

inquired into. A careful examination as to the condition of the bladder and 
urethra should be made, to see if there is any deficiency or abnormal 
arrangement of these parts ; the urine should be examined for excess of uric 
acid, also for albumen and sugar. 

Diurnal incontinence is much less common than nocturnal, though 
frequent micturition without any actual inability to retain urine is common 
enough ; in such cases the sources of irritation already mentioned should 
be sought for and removed. Sometimes a child, the subject of nocturnal 
incontinence, passes urine frequently by day, but is able to retain it. 

Ordinary nocturnal incontinence (or enuresis, as it is sometimes called) 
is more common in boys than in girls ;* it may occur at any age before 
puberty, but very rarely persists beyond that time ; if it does so it is usually 
incurable, and this rare condition is said to be most often met with in girls. 

The discharge of urine may take place once or several times during the 
night ; perhaps most often during the first sound sleep, and again in the 
early morning. 

In cases of nocturnal incontinence those conditions which have been 
mentioned as giving rise to a frequent desire to pass urine during the day 
should be looked for, since, when the child is awake, he may be able to 
control the flow, or pass his urine in a suitable place ; while during sleep no 
such power is exerted. Other causes, such as unduly deep sleep, due in some 
cases to the semiasphyxiated condition caused by enlarged tonsils or post- 
nasal adenoids, 1 dreams in which the child imagines that it is properly 
passing its water, gastric disturbance from late or unwholesome meals, 
temporary polyuria from free drinking of fluids at night, and perhaps mas- 
turbation, may be added to the list. We have also reason to think that mere 
delicacy of health, often conjoined with a somewhat unstable and easily 
excited mind, such as is sometimes seen in children born or brought up in 
hot climates, may give rise to enuresis. Possibly in some cases renal calculus 
or pyelitis of tubercular origin may give rise to incontinence. 

Treatme?it. — Setting aside the irremediable malformations and the cases 
due to paraplegia, the first thing is to look for and remove any of the sources 
of irritation. If there is phimosis, circumcision or the breaking down of 
adhesions ; if there is a small meatus, enlargement by incision will be re- 
quired. The bladder should, of course, also be sounded in any case of doubt, 
or if the condition does not speedily yield to medicinal treatment. If the 
urine is hyper-acid or contains crystals of uric acid, or there is evidence of 
cystitis, citrate of potash or liquor potassse should be given ; the child should 
be carefully dieted and its allowance of meat curtailed, while any irritating 
vegetable food, such as rhubarb, should be forbidden. Late meals should 
not be allowed, nor should the child take any fluid for an hour or two 
before going to bed. Too great a weight of bed-clothes and the' habit of 
sleeping upon the back should be avoided ; in the latter, the immediate 

1 Dr. L. Freyberger found on inquiry that in 350 cases of enlarged tonsils, there was 
enuresis in 104 ; but 193 of these were complicated with other troubles, such as phimosis, 
worms, indigestion, &c. Of the uncomplicated cases (157), only 26 had enuresis, while in 
the other class (193), 78 had enuresis. He comes to the conclusion that in uncomplicated 
cases of enlarged tonsils only some 16 per cent, will have nocturnal incontinence ; while in 
the complicated cases about 40 per cent. It is obvious that the inquiry is a difficult one. 



616 Diseases of the Genito -urinary System 

impact of the urine upon the trigone is believed to excite the effort to empty 
the viscus. 

For nocturnal incontinence alone the most successful drug is undoubtedly 
belladonna, or, still better in some cases, atropia. Belladonna should be 
given in full and increasing doses : for a child two years old it is well to 
begin with five or ten drops of tincture three times daily, and increase the dose 
by five drops every twelve hours till the physiological effects are produced, 
bearing in mind that children are not readily susceptible to the action of the 
drug ; as soon as this point is reached the dose should be continued for 
several days. If the treatment is successful, it should be continued for a 
week, and then the dose gradually diminished, increasing it again if there 
is any relapse. We have seen liquor atropiae given at night in 2-minim 
doses, reached gradually, cure a child two years old in which belladonna 
had failed. The drug probably acts both by stimulating the contraction 
of the sphincter muscles and by acting as a sedative. Bromide of potassium, 
alone or with belladonna, ergot, cantharides, nitrate of potash, camphor, 
and other drugs, has been employed. Strychnine is chiefly of use in 
diurnal incontinence, though sometimes it succeeds in the nocturnal form ; 
it is said by Bouchut to be a dangerous drug for children. Such treatment 
as blistering, or painting over the orifice of the urethra with nitrate of silver, 
or the use of a perinatal truss, is not to be recommended. The child should 
be made to pass water just before going to bed, and should be taken up again 
in an hour's time, and if possible once again during the night ; he should be 
encouraged to try to control the inclination and to exert his will, but on 
no account should he be threatened or punished, except possibly in the 
exceptional cases when, as sometimes happens, the presence of one child 
with incontinence in a school induces an epidemic, as it were, among the 
others ; in such instances probably the affection is in the acquired cases 
simply a trick, and maybe controlled by fear of punishment. The disastrous 
results of frightening such children into tying strings round the penis, as well 
as the misery inflicted by the shame of believing that what is really a disease 
is a fault, are sufficient arguments against such cruelty. Cold sponging to 
the perinaeum is sometimes useful, and we have known the use of the constant 
current, one pole being applied above the pubes and the other in the 
perinaeum or over the sacrum, to succeed where other means have failed ; 
the interrupted current also sometimes answers. The application -of nitrate 
of silver to the neck of the bladder is advocated by Holmes. In weakly 
children and in cases of diurnal incontinence, when no organic cause can be 
found, tonics, iron, strychnine, good food, and sea air will often prove 
successful, and we have known sea air cure enuresis. The possible existence 
of chronic renal disease or diabetes must be borne in mind. 

In inveterate cases in girls dilatation of the urethra and exploration of 
the bladder may, as pointed out by Owen, cure the affection even if no 
organic disease is found. 

Retention of Urine. — The causes leading to retention of urine are 
mentioned under their several headings, but it may be convenient here to 
group them together. They are congenital malformations, impacted calculus, 
phimosis, ruptured or strictured urethra, including stricture of the meatus, 
pressure on the urethra by abscess or a new growth, blocking of the orifice 



Retention of Urine — Extroversion of Bladder 6iJ 

of the urethra by a vesical or prostatic tumour, or, lastly, the tying of a string- 
round the penis. It must be remembered that retention of urine may be 
voluntary, or imaginary on the part of the friends : voluntary where the 
passage of the water causes pain, as is often seen after circumcision, 
when the urine flowing over the surface causes discomfort. We have never 
seen any harm other than alarm to the friends result from this voluntary 
retention, though it is well in such cases, if a warm bath does not relieve 
the retention, to pass a catheter into the bladder. Lastly, retention must not be 
confounded with suppression of urine from any cause. Of course, retention of 
urine if unrelieved will lead to extravasation, the treatment of which is free 
incision deeply into all the infiltrated tissues, so that a free outlet for the urine 
already extravasated is provided, as well as any further mischief prevented. 

Malformation of the Genito-urinary Organs. Extroversion of the 
Bladder. — Deficient closure of the ventral laminae, giving rise to hiatus of 
the abdominal wall, has already been mentioned in connection with umbilical 
hernia (p. 156). In certain, not rare, instances, however, the lower part of 
the abdominal wall, from the umbilicus or its neighbourhood downwards, 
may fail to close, and coupled with this there may be deficiency of the 
anterior wall of the bladder, constituting the condition known as extroversion 
or exstrophy of the bladder, ectopia vesicae, or hiatus of the bladder. A 
patent urachus or even a protrusion of the bladder wall through such a passage 
may also be found ; vide Tanner, ' Diseases of Childhood.' In this condition 
the lower part of the abdomen presents a red rugous area covered with 
mucous membrane, which is usually excoriated from friction and irritation, 
often more or less coated with mucus and phosphates. From this surface, 
or rather from the orifices of the ureters exposed upon it, the urine continu- 
ously dribbles, keeping the child always wet, and leading to irritation of the 
neighbouring skin. This red mucous surface is the posterior wall of the 
bladder, which is usually flush with the abdominal wall ; hence in most 
cases there is no bladder cavity, though occasionally there is a slight depres- 
sion. More often the surface is corrugated and somewhat protuberant, and 
on drawing down the penis, which is always distorted and ill developed (vide 
Epispadias), the orifices of the ureters can be seen, and drops of urine may 
be watched flowing from them, and often escaping in a little jet when the 
child cries or strains. The malformation is most common in males. 

On further examining such a child, it will usually be found that the 
symphysis pubis is deficient, the two bones failing to meet in the middle line, 
and being only connected by fibrous tissue. The umbilicus may be absent 
altogether, or may be more or less well formed. The scrotum is always 
imperfectly developed, and the testes do not fully descend, usually lying in, 
or just outside, the inguinal canals. Very commonly there are inguinal 
herniae developed, and these may even become strangulated. We have had 
occasion to operate in such a case. 1 

1 According to Dr. Champneys, St. Bartholomew s Hospital Reports, 1877, extrover- 
sion may be associated with talipes and other deformities ; the sex may be doubtful from 
external appearances ; there may be rectal prolapse, with a long, loose, rectal mesentery. 
All grades of deformities, from mere separation of the symphysis pubis, with perhaps a 
hernial pouch, but no deficiency of the bladder, may be met with ; in the second degree of 
deformity there may be prolapse of the bladder, though it is itself perfect ; the prolapse 



618 Diseases of the Genito-urinary System 

This deformity, which is quite unmistakable, gives rise to much trouble, 
both from the constant wetting and excoriations as well as from the in- 
capacities associated with it. It is impossible in most cases to fit any 
apparatus satisfactorily to receive the urine. Hence the treatment is solely 
operative ; and even this, it must be confessed, is not always satisfactory. 
Attempts have been made to divert the ureters into the intestine, but not 
hitherto with success (T. Smith and Simon). Holmes, Ayres, Wood, Greig 
Smith, and others have devised operations for covering in the exposed 
bladder ; these consist of dissecting up a flap from the abdominal wall or 
scrotum, and turning it over the bladder surface, subsequently covering over 
the raw side of the flap with other superimposed flaps from the groins. For 
details of the operation we must refer to works on operative surgery. Several 
successive attempts are often required before a good result is obtained, and 
there is sometimes a tendency for the flaps to retract and leave the lower 
part of the bladder exposed ; this difficulty is met by subsequent attachment 
of the flaps to the scrotum or labium below, a plan suggested by Mayo 
Robson, 1 and one we have found of value. On the whole, the result of our 
experience is that the operation should certainly be done in all cases where 
the child is in a condition to bear a somewhat severe and prolonged manipu- 
lation, and that a great improvement may be expected as a final result (fig. 
135). The child should not be operated on until it is three or four years 
old. It has been proposed to scrape or cut away the mucous surface of the 
bladder except at the orifices of the ureters, and thus avoid irritation of an 
exposed mucous membrane ; we are trying this method now. 2 After opera- 
may take place through the urethra or urachus (Vrolik, Froriep) ; the third degree is the 
ordinary form ; while in the fourth and most severe degree there is extroversion and divi- 
sion of the bladder into two halves by the opening of the intestine between them. The 
condition really arises from the fact that the allantois is developed by two lateral portions 
which afterwards meet in the middle line, and thus the various degrees of deformity of the 
bladder, epispadias &c. are explained {vide Balv in Miiller's Physiology). Union between 
the halves of the allantois takes place at the third week of foetal life, so the deformity must 
exist at that time. 

The condition of the umbilical vessels is inconstant : they may run separately to the 
placenta (Dietrich). The umbilicus is lower than usual, and the anus is generally more 
anterior than usual. Hernias are inconstant. The external genitals may be deficient 
altogether or developed in varying degrees ; the testes may be retained, or may descend 
into the scrotum and be well developed. The symphysis is not always ununited ; when it 
is so it causes awkwardness of gait. 

As Tenon pointed out, the malformation is not a cleft of the bladder merely, since 
there is a deficiency of all excepting the trigone and neighbouring parts. The pelvis of 
the kidney and the ureters are usually dilated, and may open into the rectum, vagina, or 
urethra. 

The intestine is variously malformed or deficient, and there maybe imperforate or mis- 
placed rectum. 

For further details and references Dr. Champneys' able paper should be looked at ; 
from it much of the above is taken. 

1 Brit. Med. Jour. January, 31, 1885. 

2 Excision of the bladder, with or without transplantation of the ureters, direct suture 
of the vesical margins, with or without section of the sacro-iliac joints, to allow approxima- 
tion of the rami of the pubes have also been suggested ; but no sufficiently encouraging 
results from these methods, except in one case of Wyman's, have been obtained. A good 
summary of the various operations will be found in Ann. des Mai. des Organes Gd?iito- 
urinaires, March 1888, by Pousson. 



Extroversion of Bladder 



619 



tion one of the troubles is the constant formation of phosphatic deposit 
about the parts ; careful cleansing and daily syringing with a dilute acid 
solution is required. We have found hydrochloric acid \\ xx, glycerine 5 h 
water ^ i 3 a useful form of wash. If, however, as is sometimes the case, the 
deposit persists in spite of these measures, we have found that scraping it 
away from time to time with a sharp spoon is the most effectual means of 




Fig. 135. — Shows the result of a plastic operation for Extroversion of the Bladder in a boy 
A urinal can be worn over the orifice now remaining, a points to the glans penis. 



getting rid of it. When the bladder surface has been covered in as shown 
in the figure, an appliance is readily adapted to receive the urine. 

In extroversion of the bladder in the male the penis is nearly always 
deformed, the corpora cavernosa are deficient to a greater or less degree, and 
the corpus spongiosum is ununited on its upper surface, so that the floor of the 
urethra is exposed on the dorsum of the penis. The whole organ is stunted 
and turned up against the abdomen ; the prepuce is usually redundant below, 
and the glans is generally better developed than the rest of the penis. 



620 Diseases of the Genito-urinary System 

Epispadias. — The condition of penis above described may occur without 
extroversion, constituting epispadias. 1 In such cases there is usually imper- 
fect power of retention of urine from deficient muscular development at the 
neck of the bladder, and for sexual functions the organ is useless. In such 
cases an apparatus is readily applied to prevent the discomfort of constant 
wetting ; but to improve the power of urination, and perhaps the sexual 
function, operations may be performed, consisting in either turning down a 
hood-like flap from the front of the abdominal wall over the urethral groove, 
or in dissecting up flaps of skin and bringing them over the dorsum — or, 
lastly, in taking a flap from the scrotum and turning it upwards over the 
penis, which is passed through a slit in the centre of the flap. Any small 
fistulous openings left after union of the main flaps are closed by subsequent 
operation or by repeated application of the actual cautery. In all such 
operations it is a good plan, as a preliminary step, to open the urethra or 
bladder through the perinaeum, so as to allow the urine to drain away freely, 
without flowing over the wound. Our colleague, Mr. Hardie, and Mr. 
Howlett, of Hull, have adopted this plan with good results. 

Hypospadias. — When the floor of the urethra, together with the corpus 
spongiosum, is deficient to a greater or less degree, the deformity known as 
hypospadias is present. In the slighter cases the deformity is merely one 
of the urethral orifice, which opens on the under surface of the glans penis 
instead of upon its apex, though even in these cases the corpus spongiosum 
is always thinner and less developed than it should be. A dimple usually 
represents the opening of the urethra, or a groove may run on from the 
existing opening to the end of the glans. All degrees of malformation are 
met with from this to cases where the urethra opens in the perinasum, behind 
the scrotum. In severe cases, the corpus spongiosum being entirely deficient 
below, the penis is bent downwards and held down by fibrous bands repre- 
senting the aborted spongy body ; it is also bound down by the deficiency of 
the prepuce below, though a redundant, hood-like fold overlies the glans 
above. In the severest cases the scrotum is cleft and ill developed, and the 
testes are retained or imperfectly descended, and the arrest of development 
may be such as to give rise to doubts as to the sex of the individual ; such 
are the majority of the so-called hermaphrodites. 2 

The slighter degrees of deformity, where the urethra opens at the base of 
the glans, need no treatment, and do not interfere with either the urinary or 
sexual functions as a rule, though we have met with a case where this 
condition was associated with incontinence of urine and fasces, probably 
due to deficient development of the sphincters of both outlets. In all cases 
of hypospadias a probe passed into the urethra will show how thin the 
lower wall is, and the meatus is often contracted and insufficient. Sometimes 
the opening is sufficiently far forwards to serve all purposes, but the penis is 
tightly bound down to the front of the scrotum. In such cases the organ 
may be liberated by careful dissection, but unless great caution is observed 

1 A case of epispadias in a girl is recorded by Smith in Brit. Med. Jour. September 20, 
1884. 

2 Sometimes the urethra is continued on to the glans, but there is a congenital urethral 
fistula further back, even within the rectum, and urine escapes by both orifices. For 
details of the various forms of hypospadias vide Med. Chron. December 1894. 



Hypospadias 62 1 

the thin floor of the urethra will be cut through, and a urinary fistula result. 
Where the opening is further back than half the length of the penis an 
operation may be performed to lengthen the channel ; with or without a 
preliminary cystotomy or urethrotomy, flaps should-be dissected up from the 
sides of the penis and turned over one another (method of superimposed 
flaps). This is a successful plan, but even it often fails from non-union, or 
breaking down again after partial adhesions. We more often perforate the 
prepuce and bring up the glans through it, and then, after refreshing the 
edges of the preputial fold and of the urethral furrow, unite them, completing 
the new floor of the urethra by subsequent operations. 

Congenital Contraction of the Meatus Urinarius and Congenital 
Stricture of the Urethra have already been mentioned. We have met with 
two instances of the latter : one, seen in adult life, was remedied by catheterism 
in the ordinary way ; in the other, an infant, there was retention of urine, 
with overflow. On passing a catheter two distinct obstructions were found, one 
at the front of the scrotum, and the other in the prostatic region ; they appeared 
to be definite bars of thickened tissue, the latter closely simulating prostatic 
enlargement, which, if it existed, only affected the middle lobe. 1 

Congenital contraction of the meatus may become an important affection, 
giving rise to incontinence, to retention and consequent cystitis, and indeed 
to all the secondary troubles associated with obstruction to the urinary out- 
flow. In one instance a boy of five years old was brought to us, who was 
said to have had gonorrhoea for three years, and was believed to have been tam- 
pered with ; there was a distinct gleety discharge, and the meatus was very 
small. All the symptoms disappeared after slitting the meatus and passing a 
catheter a short distance down the urethra at frequent intervals for a few weeks ; 
the child was subsequently neglected, and re-contraction took place. The 
following case further illustrates the evils of a narrow meatus : 

Contracted Meatus Urinarius. Retention. — Jas. F. , age 4 years ; admitted December 7, 
1882. Well till five weeks before admission, when he was unable to pass urine without 
pain ; subsequently had pain in hypogastrium and became ill in himself ; never passed 
blood : was catheterised at the out-patient room twice, and once passed urine voluntarily. 
On admission was found to have a contracted meatus, and was catheterised, a small 
instrument (size not recorded) being passed ; urine clear, sp. gr. 1028, faintly acid, slight 
sediment of mucus and phosphates on standing, no albumen ; the edges of the meatus 
were found to become glued together, and he was unable, even by violent straining, to pass 
urine himself; the bladder contracted tightly round the catheter. December n, the 
meatus was incised to enlarge the orifice, and a No. 8 silver catheter passed daily through 
the meatus, but not into the bladder. He was discharged on the 17th with all his sym- 
ptoms relieved. It is usually said that retention in children is always due either to impacted 
calculus or extreme phimosis. Here probably some balanitis led to ulceration and cica- 
tricial contraction of the meatus, the edges of which were probably acting as valves, which 
shut by the pressure of the urine. 

Complete obliteration of the urethra may also be met with, as in a case 
recorded by Partridge and Watson.- Mr. Gray and others have recorded cases 

1 Dr. Mudd, St. Louis Med. and Surg. Jour. November 1883, mentions a case of 
enlargement of the middle lobe in a child of thirteen months ; the swelling proved to be a 
myoma. 

2 Path. Soc. Trans, vol. xiv. The ureters were enormously dilated ; one kidney was 
atrophied, and the colon ended in the bladder ; other deformities also existed. Another 



622 Diseases of the Genito-urinary System 

of double urethra one on the dorsum and the other in the normal position, 
both communicating with the bladder, though not with each other. 1 

Prolapse of the mucous membrane of the urethra in girls may be caused 
by straining ; it gives rise to pain, bleeding, and irritability of the bladder. 
Day, who describes the condition in the ' Medical News,' Dec. 1883, advises 
astringents in mild cases, and removal by ligature of the prolapsed part in more 
severe instances. Dr. Coley removed the prolapse by radial incisions and ob- 
tained a good result {vide ' Brit. Med. Jour.' November 1, 1890, also April 12, 
1890). We have met with a case of this condition in which the prolapsed 
mucous membrane was strangulated and black. It was excised, and no 
trouble ensued. Vascular growth of the meatus urinarius is occasionally met 
with in children {vide Eve, ' Lancet,' November 1889). 

We have seen one case of complete absence of the penis, the urethra 
opening just at the margin of the anus, outside the external sphincter ; the 
scrotum and testes were well developed. The child was under the care of 
our colleague, Mr. Collier. For an account of other malformations of the 
penis, such as torsion, adhesion of the penis to the scrotum, double penis, 
penile fistula, &c, we must refer to Mr. Jacobson's work on ' Diseases of 
the Male Organs.' 

Phimosis, or the condition where a long prepuce exists which cannot 
without difficulty be drawn back over the glans on account either of the 
small size of its orifice or because of adhesions, is an affection which may 
be congenital or acquired. Further, it varies much in degree : the pre- 
puce may be very long and end in a puckered, tapering point, in which 
there is but a pin-hole orifice. Tanner has found it absolutely imperforate. 
Where the opening is very small, when urine is passed it collects between the 
glans and prepuce, and ' balloons ' out the latter, or the prepuce may be 
tightly stretched over the glans and universally adherent to it. 

In most children at birth the prepuce entirely covers the glans, and on 
withdrawing it adhesions are very often found between the two, while the 
coronal groove is filled up with retained smegma in round lumps ; if these 
adhesions are not broken down and the glans kept clean, secondary inflam- 
mation is apt to occur (balanitis) and give rise to still further adhesions, with 
perhaps increased contraction of the prepuce. In most cases, with a little 
trouble, the foreskin can be drawn back, the adhesions being torn down by 
the finger and thumb or a probe ; the adhesions are frequently non-vascular, 
at other times a few drops of blood escape. Daily retraction and cleanliness 
for a week or two get rid of all further trouble, occasional drawing back 
and washing being all that is afterwards required. 

If phimosis is neglected, many ill results may follow : retention of urine 
from obstruction at the preputial outlet or at the meatus ; as a result of such 
contraction extravasation of urine may occur, or incontinence of urine from 
irritation. Prolapse of the rectum and hernia may result from the straining- 
required to empty the bladder or from irritation ; while cystitis, balanitis, 
formation of preputial calculi, masturbation, and in later life sterility and 
increased liability to venereal diseases and epithelioma may result from 

case, treated successfully by a sort of forced catheterism, is recorded by Forster, of Darling- 
ton, Brit. Med. Jour. January 3, 1885 ; also Shattock, Lancet. February 11, 1888. 
1 Path. Soc. Trans, vol. xiv. 



Phimosis 623 

neglected phimosis. Other troubles, such as paraphimosis if a tight prepuce 
is drawn back, and, according to Mr. Banvell's view, possibly joint lesions 
from reflex irritation, may occur. Sayre also records cases of various con- 
tractions and deformities of the lower limbs resulting from phimosis. 

If the obstacle to retraction is simply the adhesions, the breaking down 
of these, already mentioned, is sufficient; if, however, the preputial orifice 
is tight, circumcision should be performed in infancy. Dilatation of the 
prepuce answers in some cases ; but we are strongly opposed to it, since we 
have seen not only rapid re-contraction but also much inflammation set up, 
necessitating circumcision and a long delay in healing ; it is not a good plan. 

In any doubtful case it is wiser to circumcise, as the operation is as harm- 
less as any operation can be if done properly. 

In every male infant the condition of the prepuce should be attended to 
during the first few weeks of life ; much subsequent trouble may be thereby 
avoided. 

There are many ways of circumcising, of which we will only describe the 
two we prefer. Slitting up the prepuce should never be done in children : it 
is much better to circumcise properly. 

The child should be anaesthetised and then, with a pair of dressing 
forceps, the prepuce should be seized just in front of the glans, but it is not 
to be drawn forwards so as to put it on the stretch, or too much skin will be 
removed. The forceps should be held vertically, and the skin in front of 
them shaved off with a scalpel ; but at the lower part of the section the 
knife should be turned forwards so as to make a little triangular tongue of 
skin projecting from the cut edge of the prepuce ; the dressing forceps are 
now removed and the skin retracts ; the mucous membrane is next slit up 
along the upper surface of the glans with a pair of scissors, and clipped away 
all round as far as the fraenum, leaving enough rim of mucous membrane to 
readily hold the sutures ; the fraenum should not be clipped close Inter- 
rupted catgut sutures are used to stitch together skin and mucous 
membrane, generally one on the dorsum and one on each side are sufficient ; 
the little tongue flap is then stitched to the fraenum and made to cover in its 
raw surface ; by this means, which was shown us by Mr. Davies Colley of 
Guy's many years ago, rapid healing is usually obtained and there is no raw 
surface to granulate. The patient should be kept lying down for a few days. 
We often slit up the prepuce with scissors, and then clip away the required 
amount of skin ; by this means it is easier to estimate the length of foreskin 
to be left. It is better to do without any dressing, simply keeping the clothes 
away from the part by a cradle. If there is any troublesome oozing, a strip of 
lint may be wrapped round the penis, leaving the meatus exposed. Bleeding 
should be carefully arrested before putting in the sutures. Covering over the 
penis with a thick pad of cotton wool in the hollow of which a large mass of 
vaseline has been put is a good plan (Banks). 

In a perfect circumcision the edge of the prepuce will just cover the 
corona ; if too much is removed the corona is apt to remain tender and 
irritable for a long time. If catgut sutures are used they do not require 
removal. The Jewish mode of circumcision does not, we think, give such 
good results as that above described. Martin alleges that circumcision 
may produce contraction of the meatus, as a result of exposure and friction, 



624 Diseases of the Genito -urinary System 

and various secondary reflex irritations, which he has relieved by slitting 
the meatus ; but we doubt the occurrence of any bad result from circum- 
cision properly performed, and think any such troubles are more likely the 
result of the condition for which circumcision is done. 

Balanitis is often met with in children, and is usually the result of 
neglected phimosis ; the prepuce may be much swollen, and large quantities 
of pus are sometimes discharged from within it ; there is much scalding 
pain on micturition. Mild cases are readily cured by syringing out the cavity 
beneath the prepuce with warm water or lead lotion. As soon as the acute 
inflammation has subsided circumcision should be performed ; it is some- 
times necessary to circumcise at once, but in such cases the wound is apt to 
be slow in healing. 

The trick of tying a string or tape round the penis, for mischief, or to 
prevent the need of passing urine, is to be thought of in cases where a child 
is brought with swelling and inflammation of the penis ; the string may be 
completely buried in the soft parts, and may give rise to ulceration or even 
sloughing, urinary fistula, &c. 

Congenital paraphimosis is the condition where the glans is congeni- 
tally uncovered by prepuce ; it is not a very common condition, but is always 
found in hypospadias, even in the slighter degrees. 

Acquired paraphimosis is produced by retraction of a tight prepuce, so 
that the glans is exposed ; it is usually the result of mischievous meddling 
with the penis. If the prepuce is not speedily drawn forward again, the tight 
foreskin constricts the penis behind the corona and interferes with the venous 
circulation both in the prepuce and the glans : the result of this is swelling 
and pain, the swelling being chiefly of the prepuce, since its tissue is more 
lax than that of the glans. If the condition is neglected the appearance be- 
comes somewhat alarming ; there is much oedema, often redness, and some 
ulceration with distortion of the organ. Since the constriction is tightest on 
the dorsum of the penis, there is little or no risk of ulceration into the 
urethra, and still less of complete gangrene, as has been sometimes stated, 
but much trouble and no little alarm are often caused by this condition, and 
we have known it give rise to suspicions of erysipelas ; it might also possibly 
be mistaken for extravasation of urine or cellulitis. The treatment of the 
affection consists in drawing forward the prepuce again ; to do this the 
swollen foreskin should be punctured with a needle and all the serum squeezed 
out : by then drawing forward the prepuce with the fore and middle fingers 
of both hands, at the same time pressing back the glans with the thumbs, 
reduction can be accomplished, unless the constriction is very tight or of long 
standing. Another method consists in winding a piece of tape or narrow 
elastic round the penis, from the glans backwards, and so, by reducing the 
size of the glans, the foreskin can be brought over it. Where the paraphi- 
mosis has existed for more than a few days it may be irreducible ; or, if the 
constriction is very tight, it maybe necessary to divide the contracted prepuce 
behind the corona, but this is rarely required. Under such circumstances 
the swelling is to be reduced by puncture and a lead lotion dressing applied ; 
in time the parts will model down, and, though permanent paraphimosis 
usually results, no serious harm occurs. After reduction of a paraphimosis, 



Masturbation — Vaginitis 625 

if the foreskin is long and tight, circumcision should be performed, or in any 
case measures taken to prevent a repetition of the retraction. 

Masturbation. — Masturbation in children is usually the result of a long 
prepuce, or retained secretion, or of some other source of irritation about 
the pelvic organs in either sex, such as worms, balanitis, vaginitis, stone, 
&c. The treatment obviously in such cases is to remove the source of 
irritation ; circumcision is in obstinate cases desirable, both as a means of 
removing irritation and as a deterrent, while in older children, who are 
able to understand the matter, and in whom the habit is a bad practice and 
not the result of any obvious physical cause, judicious speaking, pointing out 
the uncleanness and the debasing effect of the act, is the best line of treat- 
ment. Coupled with these plans should be care in avoiding opportunities 
and, if necessary, punishment should the vice be persisted in. In all cases 
onanism should be treated first as a disease, and only as a vice when it is 
clear that no cause for it exists. 

(Edema of the Scrotum in children is sometimes met with apart from 
any obvious inflammatory condition : it maybe part of a general oedema due 
to cardiac or renal disease ; in other instances it is the result of intertrigo, 
such as is met with in fat and dirty children ; occasionally it occurs without 
obvious cause, and in such cases some source of obstruction to the lymphatic 
or venous circulation should be looked for. Erysipelas, or diffuse cellulitis 
of the scrotum, penis, &c. is also occasionally seen. In all these conditions 
attention to the general health and the use of lead lotion are usually all that 
is required. 

Diseases of the External Genitals in Females. — The congenital mal- 
formations of the external genitals of female children, apart from so-called 
hermaphroditism, are rare, with the exception of the simple adhesion between 
the labia minora of the two sides, which, as Mr. Holmes has pointed out, if 
neglected, may produce retention of menses in later life, and probably forms 
the majority of the cases of so-called imperforate hymen. The treatment of 
adherent labia is very simple ; the adhesions are broken down readily with 
a probe, and a little oiled lint kept between the labia for a few days, together 
with ordinary cleanliness, is all that is required. 

Hypertrophy of the labia or clitoris in children, though common among 
the natives of some hot climates, is very rare in this country. We have, 
however, occasionally seen it, though rarely to an extent that required treat- 
ment. In a young adult, however, we have had occasion to remove hyper- 
trophic labia, the condition having lasted some years, but whether it was 
congenital or not we cannot say. Nothing short of operation is likely to be 
of any service. We have recently seen a case in which the clitoris of a little 
child was much enlarged and caused irritation ; examination showed that 
there was adhesion of the prepuce of the clitoris to the glans, with retained 
smegma, just as in the case of phimosis in the male. 

Nasvus of the labia is seen every now and then, and is best treated by 
puncture with the actual cautery. 

Of acquired affections, simple Vaginitis, or, as it more commonly is called, 
vulvitis, is frequently met with ; it is usually caused by neglect and dirt, 
and often by the irritation of thread-worms, but is sometimes the result of 
inoculation with the discharges from other cases of vulvitis, or from older 

s s 



626 Diseases of the Gcni to -urinary System 

people by the use of dirty sponges for washing, &c. Very rarely indeed is 
it the result of attempted rape, and such charges are often brought against 
innocent persons simply because the mothers conclude that all discharges 
from the genital organs in children must be venereal ; and it should be 
remembered that some children are led to invent stories or to confirm 
suggestions made by ignorant or dishonest mothers. Even the presence of 
organisms indistinguishable from gonococci would not be conclusive. 

This simple vulvitis is very contagious in many cases and readily spreads 
from one child to another ; hence isolation, perfect cleanliness, the removal 
of sources of irritation, and the free use of antiseptic lotions such as per- 
chloride of mercury or boric acid, should be employed. In some cases 
astringent lotions, such as sulphate of zinc or alum, are useful, and iodoform 
should be well dusted into the vulva. In one instance we found prominent 
masses of granulations in the vagina in a case that had long resisted ordinary 
treatment ; in this case nitrate of silver proved the best application. 

The so-called aphthous vulvitis is a superficial ulceration occurring not 
rarely about the labia in ill-nourished, neglected, and unhealthy children, 
especially common as a sequel or complication of one of the exanthems. It 
occurs also in some cases of nephritis, and may simulate the severer disease, 
noma, from the presence of dried blood on the surface, giving the appear- 
ance of sloughing, as in the following case : 

Acute Nephritis. Ulceration of Labia. — Mabel C. , age 2 years. Admitted October 27, 
1885. Two months ago an eruption appeared on the face and head, which has lasted 
since ; for the past fortnight the labia have been swollen and sore, small spots appearing 
first ; has had epistaxis for the last few days ; is said not to have passed urine since the 
24th ; bowels open this morning, motion quite black. On admission, pale, pasty, bloated 
child ; labia both much swollen and superficially ulcerated ; no vaginal discharge ; some 
superficial ulceration around the right ear ; eczematous patches on the head, covered with 
blood-stained scabs. 28th, seems very feeble ; no urine passed until this morning, and 
then into the bed ; vulva as yesterday, some thread-worms seen about it ; eyes puffy ; does 
not take food well ; found dead in bed at 9 p.m. The vulva was dressed with carbolic 
lotion and boric lint, and carbonate of ammonia and bark, with strong beef tea and 
wine, given. Temperature, 28th, M. 98 '2°, E. 96 - 6°. 

Post-mortem.- — Both lungs rather congested and cedematous ; no pneumonia; heart 
normal; kidneys swollen; weighed together 3 oz., not very congested; in one, cortex 
finely granular (like scarlatinal nephritis) with red points ; the ulceration on the vulva and 
head were quite superficial ; there was no sloughing ; it extended all over vulva to the 
vaginal orifice. 

The treatment consists in cleanliness, free stimulation, and abundant 
nourishment, together with such measures as the disease with which it is 
associated demands. 

According to Savarin aphthous vulvitis occurs most commonly in children 
of from two to five years, and usually is a sequel of measles ; the patches 
begin as blisters and then ulcerate ; they may finally become gangrenous. 
There is some fever and the parts around are swollen, but there is very rarely 
lymphatic enlargement. The labia majora are most often affected, but the 
process may spread to the perinaeum, groin, &c. The disease has a certain 
resemblance to diphtheria and syphilis, but is distinguished from the former 
by the imperfect membrane formation, and from both by the multiplicity of 
the ulcers, the absence of lymphatic enlargement, and the history. The 



Noma Pudendi — Irritable -Mamma 627 

prognosis is favourable unless gangrene occurs, and the best applications 
are boric acid and iodoform. 1 Tuberculous ulceration may be met with 
about the vulva as in other parts. 

Noma Pudendi. — Noma pudendi or noma vulvas is a gangrenous affec- 
tion of the external genitals, of precisely the same character as cancrum oris ; 
it runs in similar course, occurs under the same conditions, and requires the 
same treatment. It is quite as fatal as cancrum oris, if not more so ; it 
is, however, much rarer : many of the cases of so-called noma are merely 
aphthous vulvitis. We have very rarely seen well-marked cases. Morse 
has found an organism in noma that he regards as pathogenic.' 2 

Warty and cystic growths are mentioned by Mr. Holmes and others as 
having been met with about the vulva and vagina in children, and would 
require treatment on general principles. 

Haemorrhage from the vulva or vagina is occasionally met with in infants, 
but is of trivial importance and requires no treatment (Holmes) ; vide chapter 
on Diseases incidental to Birth. 

Irritable Mamma, — Irritable or painful mammae are not uncommon in 
girls of from ten to fifteen years. There is slight enlargement of the glands, 
which are tender ; the pain is variable ; usually one breast is affected at a 
time and the other is attacked later. This condition is usually met with 
before menstruation has occurred, but is probably associated with the physio- 
logical growth of the organs. A similar condition is met with to a less 
marked degree in boys about puberty. Occasionally the condition is simply 
hysterical. Treatment seems to be of little use, but all the cases we have 
seen have got well. Belladonna and strapping locally, with tonics and arsenic 
internally, should be tried. 

In infants the breasts occasionally suppurate ; this is usually the result 
of rough handling on the part of superstitious nurses, 3 and may result in per- 
manently stunted or retracted nipples. 

Abnormalities in the Descent of the Testicles. — In the fully developed 
child the testes should be in the scrotum at birth, or rather shortly before 
birth ; 4 it is not, however, rare for their descent to be delayed for varying 
periods — they may even pass into the scrotum as late as the time of puberty. 
Most commonly descent takes place between the second and tenth years 
(Hunter, quoted by Jacobson) ; if the testicle does not come down by the 
end of the first year, Curling says it is usually accompanied by a hernia. In 
some instances the organs are permanently retained within the abdomen 
(cryptorchism) ; sometimes one testicle descends, the other being retained 
(monorchism). When the testes have not reached their proper situation 
they may be found in the abdomen, at the internal ring, in the inguinal 
canal, in the upper part of the scrotum, in the perinaeum, or even in the 
thigh; 5 and instances of descent of the testes through the femoral canal 

1 Vide Savarin, Rev. Mens, des Malad. de V Enfance, May 1884. 

2 Med. Record, January 1885. 

5 The breasts are pulled at to 'break the nipple strings,' with the idea of preventing 
retraction of the nipples in later life. 

4 Camper found the testes in the scrotum at birth in sixty-three cases out of seventy. 

5 Displacement of the testes into the thigh has been accounted for by the fact that 
some fibres of the gubernaculum testis pass downwards into the upper part of the thigh. 

ss 2 



628 Diseases of the Genito-nrinary System 

are on record. Usually the glands are movable, and, though they may 
generally occupy one particular position, they may often be drawn down 
or pushed up beyond that spot, just as their situation alters according to 
the contraction or relaxation of the cremaster and dartos under ordinary 
circumstances. 

• The cause of failure of natural descent of the testicles is still somewhat 
obscure. Possibly failure in the action of the gubernaculum, possibly simply 
a lack of development ; certainly sometimes adhesions to surrounding parts, 
to the funicular process, the intestine, or the mesentery, prevent the descent. 
Premature closure of the funicular process, contraction of the inguinal rings, 
or a deficient development of the scrotum in some cases, perhaps accounts 
for the failure ; other less frequent causes, such as shortness of the vas 
deferens, a long mesorchium, allowing the testis to float freely in the 
abdomen, fusion of the two testes, or an enlarged epididymis, are mentioned 
by Jacobson. 1 

The condition of the glands when they are in an abnormal position is a 
question of importance : they are often imperfectly developed. In other 
cases, however, they are in no way defective, and cryptorchism by no means 
necessarily implies sterility, while monorchism is, of course, functionally still 
less important. 

Apart from functional imperfection, various evils may attend imperfectly 
descended testes. From their abnormal position and diminished mobility 
they are in many cases more exposed to injury, as, for instance, when they 
are lodged in the perinaeum or in the canal. If a testis becomes inflamed 
from injury or other cause, the symptoms are likely to be much more serious 
if the gland is retained within the abdomen or in the canal, while retained 
testes are said to be frequently the seat of new growths. 2 Most important, 
perhaps, of all is the effect of an imperfect descent of the testicle upon the 
formation and persistence of hernia. But keeping the inguinal canal and 
rings open, the misplaced organ directly encourages the descent of a hernia. 
Where the gland acquires adhesions to the bowel and then descends into 
the canal, or even where the adhesions result from descent of a hernia after 
the testis, the matter is still further complicated, and great difficulty in the 
management of such cases may arise. 3 It is quite common for a child to be 
brought with the statement that it is ruptured, and that it has perhaps been 
wearing a truss — but this is said to have been always painful, and the child 
screams all the while it is on. Examination shows an undescended testis 
lying in the canal, which has been pressed upon by the truss, and, of course, 
the child could not bear it. In such cases the undescended testis is often 
the supposed hernia, though frequently enough the two conditions co-exist,, 
and a reducible hernia is found to descend above the testicle. We have 

1 Diseases of the Male Organs of Generation, 1893 ; vide also Lockwood, Brit. Med. 
Jour. 1887. 

2 Especially, according to Virchow, when they are retained in the inguinal canal ; he 
points out that obscure abdominal tumours, in the absence of any more obvious connec- 
tion, should induce examination for an undescended testis. 

5 The caecum may descend with the testis inconsequence, possibly, of unusual strength 
or abnormal arrangement of that portion of the mesorchium called the ' plica vascularis * 
{vide Lockwood, Med. Chir. Trans. 1886). 



Undescended Testis 



629 



met with a case in which both testis and hernia were strangulated ; we 
removed the testis, closed the canal, and the patient made a good recovery. 

The late Mr. John Wood made some valuable remarks upon this subject in 
his lectures published in the ' British Medical Journal,' June 1885. Where a 
hernia and an imperfectly descended testis co-exist, the gland, if wasted, may 
be removed ; if adherent to the bowel it may be returnedjjwithin the abdomen, 
and the ring closed, or, if possible, may be separated, drawn down into the 
scrotum, and fixed there, the sac and canal being closed above it. In 
funicular hernia a tunica vaginalis may be made by detaching part of the 
funicular process, and bringing it down into the scrotum ; if the cord cannot 
be drawn out enough to let 
the gland come down, the 
epididymis may be loosened 
from the testis, and the latter 
turned down so as to reach the 
scrotum. All Mr. Wood's re- 
sults in these operations were 
' good,' with one exception. 
The diagnosis of undescended 
testis is not often a matter ot 
difficulty : an examination of 
both sides of the scrotum will 
generally clear up the case. 
But we would suggest a word 
of caution not to be satisfied 
with too cursory an investiga- 
tion : sometimes one testis 
maybe down, and, unless both 
are felt for at the same time, 
may slip about so as to feel as 
if it belonged to either side ; 
sometimes, too, an empty 
scrotum may be felt, but a 
little examination and mani- 
pulation of the canal, or. the 
application of heat, may bring 
down the testicle, and the case 
may turn out to be merely one of 
retracted, not retained, testis. 

Occasionally a hernia, if it contains thickened omentum or glands, may 
be taken for a testicle or a hydrocele of the cord, or a fibrous or fatty tumour 
may simulate a testis in the canal. There is considerable variation in the 
size and firmness of the testes of young children, and we have frequently 
seen mistakes made about these conditions. 

The treatment of undescended testicle is an important and difficult 
matter. Where in an infant or child three or four years old there is an 
undescended or imperfectly descended testicle, with no hernia, nothing 
should be done except gentle attempts to bring the glands further down by 
pressure from above with the fingers ; this manipulation should be repeated 




Fig. 136. — The right testis is undescended, and is seen 
forming a swelling in the inguinal canal. 



630 Diseases of the Genito-urinary System 

frequently during the day. In an older child, up to the age of puberty, the 
same line of treatment should be adopted as a rule ; if, however, the testicle 
gives rise to pain or trouble, an attempt may be made by operation to bring 
it down and fix it to the bottom of the scrotum. Mr. Wood had some 
successes, as already stated ; we have performed the operation in a good 
many cases, but though it is sometimes successful we have found that there 
is a great tendency for the testes to again become retracted. The scrotum 
in such cases is often small and ill developed. The operation consists in 
exposing the testis as in an operation for hernia, and passing a silk or 
catgut stitch through its outer tunic, or between the gland and the 
epididymis, and then bringing the suture out at the bottom of the scrotum 
and fixing it there. Testis in perinaio is probably best treated by replacing 
it in the scrotum — by operation, if possible ; if not, and its presence gives 
rise to trouble, it should be removed. Mr. Jacobson advises that all such 
operations should be postponed till after the first or second year. It is 
essential to freely separate the testis from all the adhesions which usually 
exist, so that it lies quite readily in its new position, even before it is 
stitched there. The adhesions may be remains of that part of the guber- 
naculum which is attached to the tuberosity of the ischium, and this may 
explain the abnormal position of the testis. 1 Displacement of the testicle 
into the perinaeum is sometimes the result of dislocation, and is not con- 
genital : under such circumstances it has been successfully replaced. 2 

We must strongly protest against the use of a truss for undescended 
testis in young children with a view of keeping it out of the way, or preventing 
the descent of a hernia where no rupture already exists ; we cannot but con- 
sider the plan unnecessary and unscientific except in the cases where the 
testicle is inseparably adherent to the bowel, and, as this can only be ascer- 
tained by operation, we think it is wiser to operate in doubtful cases, separate 
the testis, bring it down, and close the canal above it if possible. If this cannot 
be done, the testicle should either be removed — which should be only done, 
as a rule, when the testicle is small and wasted, and can be separated from 
the gut without risk of injury to the bowel — or, after reducing it into the 
abdomen, the canal should be closed ; hence it is only in such cases that 
any obstacle to the descent of the testicle should be interposed. 

Should an undescended testis become inflamed from injury, from torsion 
or from pressure while in the canal, the symptoms may be severe, -and may 
simulate those of strangulated hernia — the absence of the gland from the 
scrotum usually clearing up the doubt ; if, however, there is any uncertainty 
about it, or the symptoms do not speedily subside, the parts should be ex- 
plored, and the inflamed or gangrenous testis is generally better removed. 
Fatal peritonitis has resulted from this condition. 

Jacobson, in his well-known article in Holmes' ' System of Surgery ' and 
book on ' Diseases of the Male Organs,' advises the use of Dover's powder, 
hydrarg. c. creta, and hot poppy fomentations in these cases in the early 
stage ; to this work we must refer for further details on this subject : to it 
we are indebted for many of the points in the present chapter. 

Where a hernia co-exists with an undescended testis, but the two are not 

1 Vide Lockwood, Med. Chir. Trans. 1886. 

2 Victor Horsley, Med. Times and Gazette, December 1883. 



Displaced Testis — Supernumerary Testicles 631 

adherent, the best treatment is to apply a truss of special size and shape for 
the particular case, made so as to fit between the testis and the canal, and so, 
while the rupture is kept up, the testis is pressed downwards. We have 
employed this plan usefully, and by its means both defects may be cured. 
Should the truss fail to procure closure of the canal, the hernia should be 
dealt with by the operation described in p. 159 ; the funicular process being 
closed above the gland, the descent of the testis will be favoured, and an 
attempt may be made at the same time to fix it in the scrotum. 

Supernumerary testicles hardly ever occur. Most of the supposed in- 
stances have turned out to be either hydroceles of the cord, hernias, or solid 
tumours. Lane has, however, recorded a recent case. Congenital absence 
of the testes as distinguished from mere cryptorchism is an exceedingly rare 
condition and usually associated with other malformations. 

Deficiency or closure of the vas deferens is occasionally met with : in 
such cases the testis is well developed, but, of course, functionless. Inverted 
testicle, where the epididymis lies in front of the gland, is sometimes a con- 
genital, sometimes an acquired condition ; it may be of importance in case 
of the appearance of a hydrocele or hernia, or as a predisposing cause of 
torsion of the testicle. 

Mr. Jacobson's table of the complications of misplaced testis, in so far as it relates to 
children, is here summarised : 

1. The testis ma}- be retained (a) in the abdomen, (b) in the iliac fossa, (c) in the 
inguinal canal, (d) just outside the external ring. 

2. The testis may take an abnormal course into (a) the perinaeum, (b) the crural 
canal. 

3. Retained testis may become inflamed or gangrenous, may give rise to peritonitis, 
may simulate a strangulated hernia, or may become the seat of tuberculous disease, or 
of malignant growth, or may atrophy. 

4. Misplaced testis may be complicated with hernia, (a) from adhesion of intestine to 
the undescended testicle, or {b) from co-existing patency of the funicular process. 

5. Hydrocele may be a complication, as (a) an acute condition from inflammatory 
effusion into some unobliterated portion of the processus vaginalis, or (b) as a chronic 
effusion ; in either case there may be a communication with the cavity of the peritoneum 
above, or extension into the scrotum below. 

Congenital displacement or Hernia of the ovary sometimes occurs, 
one or both organs protruding into the inguinal or even into the femoral 
canals, and occasionally in later childhood a similar malposition occurs. We 
have seen both ovaries prolapsed into the inguinal canals in a case of tuber- 
cular ascites, the ovaries returning to the abdomen on the subsidence of the 
fluid. If irreducible, the ovaries may give rise to trouble in later life from 
their enlargement at the menstrual periods, as well as from their presence 
keeping the inguinal canals patent : hence, where possible, they should be 
returned to the abdomen and kept back by a truss ; occasionally an opera- 
tion as for hernia is required. Torsion of an ovary prolapsed through the 
inguinal canal has been recorded. 

Diseases of the Testicle in Childhood. — Simple acute orchitis in 
children occurs as a result of injury — undue pressure of a truss — orthe result 
of an operation such as that for the radical cure of hernia or lithotomy ; some 
times without assignable cause, or under circumstances mentioned in the 
case of hydrocele. The inflammation often results in the development of 



632 Diseases of tlie Geniio -urinary System 

hydrocele, and there is often oedema of the scrotum ; but the affection is 
seldom severe, and subsides readily under the use of lead lotion, rest, and 
elevation. We have never seen any immediate bad result, though it is 
possible that the subsequent growth of the gland may be interfered with. 
Orchitis from mumps is very rare in childhood ; we have never seen it. 
Acute inflammation of the testis going on to gangrene may be a result of 
' torsion ' of the testis, an accident occasionally met with, usually occurring 
in cases in which there is some abnormality of the organ, and very apt to be 
mistaken either for an acute orchitis from some other cause, or for strangu- 
lated hernia, especially if, as is often the case, the testis has imperfectly 
descended. Chronic orchitis may result from the acute form. 

Syphilitic Testitis is, in our experience, very rare ; Mr. Holmes 
mentions having seen hard knots in the testicle which were apparently 
gummatous ; they readily yield to the use of hydarg. c. creta. Other cases 
have also been recorded, and sometimes a diffuse orchitis is found. We 
have met with cases of induration of the testes in young children for which 
we have been unable to account. 

Tuberculous disease of the testicle is met with in two forms : as a part 
merely of a general tuberculosis, and as a localised condition limited to the 
testis alone or the genito-urinary tract. Genito-urinary tuberculosis is much 
rarer in children than in adults, but it is common to find both testes tubercu- 
lous. In the former case the tubercles may be only miliary and disseminated, 
and hence not recognisable during life, or they may form definite, hard, 
circumscribed masses in the epididymis, just as in adults. While the disease 
is limited to the testicle, it takes the form just described, giving often a 
sensation as of a ' dumb-bell ' or double testicle ; it is usually not painful, and 
often of slow growth. If nothing cuts short the child's life, the testicle 
usually at last breaks down, and a suppurating ' strumous testis ' develops, 
with its characteristic adherent or undermined skin, livid colour, and 
intractable course ; the cord is usually thickened. 

Where the tubercle is generalised, no treatment of the testicular affection 
is, of course, of any use ; when, however, no obvious lesion exists elsewhere, 
the usual management, medicinal and dietary, of these cases should be 
carried out (cod liver oil, phosphate of iron, &c). For the testicle itself, 
pressure, with occasional inunction of mercurial or iodide of lead ointment, 
may be used, but as soon as suppuration occurs it is probably better to 
remove the gland ; it is in such cases most likely functionally destroyed from 
blockage of the efferent ducts, and is a source of general infection. The 
operation is sometimes advised as a precautionary measure as soon as a 
diagnosis can be made, but the propriety of this we think open to doubt ; we 
have had occasion to perform the operation only once or twice, and in one 
case the child was seen two or three years later in good health, his brother 
being affected by ' general surgical tuberculosis.' In this instance the 
disease began at 7 weeks old, and the gland was removed at 18 months ; 
testicle and epididymis were involved. Our colleague, Professor Dreschfeld, 
has recorded a case of congenital tuberculosis of the testis in which tubercle 
bacilli were found. 1 Hernia testis occurs only in those cases where the 
body of the testis is involved, and when present castration is probably the 
1 Brit Med. Jour. 1884, p. 860. 



Tumours of the Testis 633 

wisest course. Occasionally the tubercular deposit gives rise to acute 
inflammation. 

Tumours of the Testis. — Tumours of the testis in children may be 
congenital or acquired ; the congenital are rare and usually teratomata or 
* dermoid,' consisting of cysts which contain hair, teeth, &c. as in the 
corresponding tumours of the ovary. 1 Striped and unstriped myomata, 
however, also have been found,' 2 as well as congenital adeno-sarcomata, 3 and, 
according to Silcock, 4 carcinoma — though Butlin disbelieves in the occur- 
rence of carcinoma testis in children. 

Acquired tumours are usually sarcomata (round-celled), very rapidly 
giowing, very malignant, and tending to involve the lumbar glands very 
early. The large size, rate of growth, solidity, dilated veins, opacity, and 
bossy surface sometimes with cysts, make the diagnosis usually easy. These 
growths generally occur in the first few years of life, but according to Butlin 
are common from the time of birth to the tenth year. 

Non-sarcomatous cystic disease may be met with ; the cysts usually 
arise as dilatations of the seminal tubules, and may be lined by cylindrical 
or ciliated epithelium. Immediate removal is the only treatment to be adopted 
in a case of malignant disease of the testis, though recurrence within a year 
is to be expected in most cases ; in simple cystic disease the same treatment 
is required, since a diagnosis between it and sarcoma is impossible. In the 
case of dermoid cysts it is sometimes possible to dissect away the cysts 
without injury to the testis. 5 

Hydrocele. — Hydrocele is a very common affection in childhood, most 
frequently met with in quite early infancy ; it may result from simple irrita- 
tion, intertrigo, &c, especially when, as is often the case in that condition, 
the testes hang loose and pendulous. It is sometimes caused by injury, the 
testis being squeezed by the child while keeping its legs crossed, or by other 
accidents. Hydrocele may be congenital where the whole processus vaginalis 
remains patent ; in this case if the communication with the peritoneal cavity 
remains free, the fluid will flow in and out according to the position of the 
child. We must say this condition is not often found : either the opening is 
a small one and readily occluded by flexion, or this form of hydrocele is rarer 
than is commonly supposed. 

Infantile hydrocele, so called, is the condition where the tunica vaginalis 
and funicular process are distended with fluid, the processus being closed at 
the internal ring ; this is a common condition. Again, the funicular part of 
the processus may remain open, but be shut off from the tunica vaginalis ; 
in such a case a congenital funicular hydrocele would result. Or, finally, 
there may be an encysted hydrocele of the cord from distension of an unclosed 
segment of the funicular process. 

Diffused hydrocele of the cord, described as a sort of oedema of the 

1 Teratomatous tumours of the testis are explained by Saint-Hilaire as instances of 
' fcetal inclusion ; ' by Owen as instances of parthenogenesis ; and by Lebert as the 
result of ' heleYotopie plastique.' 

2 Rindfieisch and Rokitansky. 5 R. W. Parker, Path. Soc. Trans. 1885. 

4 Path. Soc. Trans. 1885. 

5 Verneuil, Brit. Med. Jour. April 4, 1885. For a full account of testicular growths 
see Jacobson, op. cit. 



^34 



Diseases of the Genito -urinary System 



cellular tissue of the cord, is believed to be very rare ; we met with a case 
while operating for hydrocele of the cord, in which there was some gelatinous 
material lying in the tissue of the cord, superficial to the funicular process, 
which contained ordinary clear fluid. Hydrocele (encysted) of the testis, 
and epididymis from dilatation of the hydatid of Morgagni, or organ of 
Giraldes, may possibly occur ; it is, however, usually a disease of later life, 
and no case appears to have been recorded in childhood. (Gosselin.) 

Diagnosis. — The diagnosis of hydrocele in children is made by first 
examining the cord, and excluding the presence of a hernia by finding that 
there is no increased thickness of the cord above ; next, a soft, elastic, fluc- 
tuating feeling points to hydrocele ; and, finally, translucency, or the possibility 
of reduction gradually by pressure or elevation, without any gurgling sensa- 
tion, clears up the case. It is, however, certain that herniae in infants, when 
the bowel contains only flatus and is much distended, are sometimes quite 
translucent. Mr. Howse was, we believe, the first to point out this fact, 
and we have many times seen the same thing. 

When there is an encysted hydrocele of the cord it is usually possible 
to bring it down by traction, and feel the absence of thickening above, or the 
tense swelling may be made to slip backwards and forwards between the 




Congenital 
funicular form. 



Encysted hydro- 
cele of the cord. 



Common vaginal 
hydrocele. 



Fig. 137. — Diagram of the commoner forms of Hydrocele of the Vaginal Process 
Altered from Lane. 



fingers, quite unlike a hernia. The mode of reduction serves to distinguish 
a funicular hernia from a funicular hydrocele, and the absence of distinct im- 
pulse gives corroborati ve evidence. Hydrocele of a retained testis sometimes 
occurs and may give rise to difficulty ; the possibility of isolating it, its irre- 
ducibility, and its consistence, together with the absence of the testis from 
the scrotum, will give the clue. 

Combinations of two forms of hydrocele, e.g. of vaginal hydrocele with 
encysted hydrocele of the cord, may be met with, and a funicular process 
may contain fluid at one time and a hernia at another. Or there may be 
infantile hernia with infantile hydrocele. A collection of fluid may form in the 
sac of a congenital hernia, but is usually masked by the presence of bowel. 

Engel and Camper are quoted by Jacobson as having found the processus 
vaginalis closed at birth in about 10 per cent, only of children examined ; this 
supports the view that some abnormal condition of secretion in the abdo- 
minal cavity must exist to produce a congenital hydrocele, for it is certainly 
not as common as these figures would imply. 

Hydrocele in Girls. — The funicular process in girls (canal of Nuck) is 
occasionally the seat of hydrocele ; the diagnostic points and treatment are 
practically those of hydrocele of the cord in boys. 



Hydrocele in Girls — Varicocele — Ovarian Tumours 635 

Treatment. — Many cases of hydrocele get well without treatment ; those 
due to local irritation subside on removal of the cause. The congenital form 
may disappear by spontaneous closure of the funicular process ; other cases 
subside under the use of evaporating lotions, lead lotion, or mild counter- 
irritation such as painting with tincture of iodine. The congenital and funi- 
cular varieties are usually cured by a truss, and it is seldom that hydroceles 
give much trouble. When, however, these plans fail, the methods of treat- 
ment we prefer are : (1) injection with solution of pure carbolic acid in glyce- 
rine (1 part in 3) without emptying the sac of its fluid, so that the injection 
is still further diluted : (2) simple antiseptic incision : the sac is laid open and 
drained for four or five days without any stitching of the edges of the sac to 
the skin, as in the so-called ' schnitt operation,' or part of the parietal layer 
of the tunica may be excised, and so the sac may be obliterated. Tapping, 
subcutaneous puncture, letting the fluid escape into the loose scrotal tissue, 
setons, injection with iodine or spirit, &c, all have their advocates, and are 
no doubt often successful ; but the plans mentioned are in our opinion the 
safest, 1 surest, and quickest, though relapses occasionally occur, whatever 
method is adopted. We have seen a hydrocele develop some time after an 
operation for the radical cure of hernia in an infant in whom the bowel was 
strangulated. 

(Edema of the scrotum is often met with as a result of intertrigo in 
children, and should be distinguished from hydrocele, anasarca, erysipelas, 
and extravasation of urine— also from the ' inflammatory ' or ' malignant 
cedema,' so called. 

Varicocele has been met with in childhood by Bryant, Pearce Gould, 
and Landouzy, but we have never seen a case earlier than about the tenth 
year, though we have seen a boy of thirteen with a large varicocele which 
was said to have existed for five years. 

Ovarian Tumours in children are nearly always sarcomata, teratomata, 
or dermoid cysts ; 2 they may appear at any age : thus Chiene 3 has operated 
successfully at three months, and Roemer 4 of Berlin at twenty months. The 
only treatment is abdominal section in the ordinary way. In the case of 
large tumours it may be impossible to make an accurate diagnosis between 
ovarian and renal or other congenital tumours until the abdomen is opened. 
Precocious puberty has in some instances been found associated with ovarian 
tumours. W 7 e have seen considerable development of the external genitals, 
with growth of hair and discharge of blood from the vagina, in a child 
three years old, who was the subject of a tumour which apparently involved 
the liver and the right kidney. Tuberculous pyosalpinx has once been met 
with by Chaffey, and once by Quarry Silcock. 5 

1 Poland has recorded a case of fatal peritonitis after tapping a congenital hydrocele 
of the cord. — Lancet, December 1884. 

2 Evers, Si. Louis Courier of Medicine, August 1884, has met with a case of sarcoma 
in a girl of two and a half years. 

5 Edinburgh Med. Jour. June 1884. 

4 Jahrbuchf. Kinderheiik. Bd. xxi. H. 4. Eight out of eleven cases collected by 
Roemer recovered. 

5 Path. Soc. Trans. 1885. See also Tumours of the Ovary &c. by Doran. 



636 Diseases of the Bones 



CHAPTER XXIX 

DISEASES OF THE BONES 

Diseases of the Bones.— A full description of the subject of inflamma- 
tion in bone would be out of place in the present work, but a few of the more 
important points may be summarised thus : 

The process of inflammation as occurring in bone differs from that in the 
soft parts only in that the inflamed tissue is more rigid and unyielding ; hence, 
on the one hand, the progress of inflammation may be slower, and on the 
other, as tension is greater, its effects may be more destructive. 

As elsewhere, inflammation in bone leads to rarefaction, i.e. absorption of 
healthy tissue (rarefying ostitis), and this may go on slowly, and without any 
sufficient outpouring of material to develop pus or any obvious external 
signs of the changes going on. The bone slowly becomes thinner and 
weaker, and its tissue may entirely disappear ; such a change we see in 
the caries sicca, or non-suppurative caries, of the vertebrae or of the articular 
ends of the long bones. It is in some cases accompanied by a deposit of 
new periosteal bone while rarefaction is going on in the interior ; such a 
condition occurs in some instances of chronic osteomyelitis of the shaft of 
the femur after excision in hip disease. In these cases fractures may occur 
almost spontaneously, or at least from very slight violence. 

Again, in other instances, the inflammatory material may be in sufficient 
quantity, and so incapable of becoming organised that pus is formed, and 
this may infiltrate the adjacent bone, and so give rise to further extension of 
the process, without the formation of any definite abscess ; such a condition 
we see in some of the cases of chronic osteomyelitis of the long bones, 
epiphysitis, certain forms of necrosis of the jaw, &c. Under these circum- 
stances necrosis usually results, or if there is more abundant pus formation 
an abscess in bone is found. 

Where, in consequence perhaps (Cornil and Ranvier) of primary fatty 
degeneration of bone corpuscles> the bone tissue slowly dies, the dying part, 
acting as an irritant, gives rise to inflammation around, and the bone is slowly 
disintegrated, with more or less abundant formation of pus ; such a process 
is seen in ordinary caries of a rib or of the pelvis, or of the articular end of a 
bone. When small islets of bone are marked out and, as it were, cut off from 
the rest by the surrounding inflammation, minute sequestra become de- 
tached (caries necrotica), while, if larger masses are so separated by a line 
of demarcation, common necrosis results. The last-named may, of course, 
be an acute or chronic process, a slow diminution in blood supply causing 






Acute Periostitis 637 

gradual starvation, or an immediate strangulation causing rapid gangrene 
of the part (acute necrosis.) 

So-called 'condensing ostitis' or ' sclerosis' is in its results an hypertrophy, 
making the bone denser and stronger ; the new material has sufficient 
vitality to stand, and sufficient blood supply to support it as well as the 
original tissue ; such a process we see in chronic periostitis, the results of 
which may be compared with the sclerosed bone of repaired rickets. 

Should, however, this deposit of new bone go on beyond a certain point, 
the blood channels become themselves so narrowed that the surrounding 
bone is starved, and so necrosis may result. 

It should be noticed that while some of these processes of destruction and 
growth and repair are constantly seen going on side by side, as where chronic 
osteomyelitis causes central necrosis and at the same time the periosteum 
forms a new peripheral layer of bone, in others we do not see any repair so long 
as the disease is spreading : thus, in caries of a flat bone or an articular sur- 
face, until the destructive process ceases, no new bone is, as a rule, laid down. 

Inflammation in bone may occur primarily either as a periostitis or as an 
osteomyelitis, the latter, often called osteitis, attacking the endosteum and 
marrow in the medullary cavity or in the cancellous tissue. Compact bone 
can hardly be supposed ever to be the seat of a primary lesion, though 
constantly involved by direct extension along the Haversian canals from 
either periosteum or medulla, it being remembered that a thin layer of me- 
dullary tissue lies in each Haversian canal. Inflammation beginning in the 
epiphysial line may be considered as an osteomyelitis. 

Periostitis. — Acute periostitis, phlegmonous periostitis, or 'acute 
necrosis,' is a disease essentially of childhood and youth, rare in infancy, 1 
and still rarer in adult life, though we have seen it in a man of over fifty and 
in a young man of about twenty-five. These are facts of importance, since 
they show that the disease does not necessarily begin in or near the 
epiphysial line. The disease is seen in two distinct forms, corresponding to 
the anatomical structure of the periosteum ; in the one there is an acute 
inflammation, with pouring out of the inflammatory products between the 
surface of the bone and the deep fibrous layer of the periosteum (true, deep, 
sub-periosteal abscess) ; in the other the exudation takes place superficially 
to the deep fibrous layer, in the looser cellular zone which connects the 
periosteum with the surrounding cellular tissue (parosteal abscess). The 
difference in texture of these two layers is of the utmost importance, and is 
marked by striking differences in the course and results of the inflamma- 
tion. While the sub-periosteal effusion, whether serous or purulent, lifts up 
the periosteum from the bone, presses upon and detaches the vessels passing 
to the Haversian canals, and thus cuts off the blood supply to the affected 
part, and further, by the extreme tension under which it is pent in, gives rise 
to all those evil results due to pressure of confined fluid, on the other hand, 
the supraperiosteal exudation lies in loose tissue, interferes comparatively 
little with the blood supply to the bone, and is not bound down, so that there 
is but little tension. 

1 We have only twice seen it under two years old. Watson Cheyne mentions a case 
of Rosenbach's in which it occurred in titero, but this was considered to be an osteo- 
myelitis (? epiphysitis). — Brit. Med. Jour. March 3, 1888. 



638 Diseases of the Bones 

Either form of acute periostitis may be met with as a result of injury, 
exposure to cold and wet, as a sequel of one of the exanthems, 1 or as a 
pyaemic condition. It will nearly always be found that one of these causes 
has produced, or at least preceded, the attack ; often two or more may be 
combined. The disease is an infective one, and in some cases pure cultures 
of staphylococci may be obtained from the pus. 

The onset of acute periostitis is marked by fever with its general constitu- 
tional disturbance, rigors, pain in the affected limb, with swelling coming 
on rapidly, and usually involving" the whole length of the affected bone, and 
often the adjacent joints. Mr. Clinton Dent has pointed out that extension 
of suppuration to the joint is commoner in supra- than in sub-periosteal 
abscess ; it certainly does, however, occur in both forms. The skin soon 
becomes swollen, red, and shining, and there is extreme tenderness. The 
temperature commonly, in the sub-periosteal variety, reaches io3°-io5°, and 
there is much prostration. Soon the swelling increases, and, if proper treat- 
ment is not adopted, in a few days pus finds its way to the surface and is 
discharged, with much relief to the symptoms. Usually, however, fresh foci 
of suppuration arise, and, if the child is neglected, in a large number of 
instances pyaemia occurs, and the patient dies ; in others, after much 
destruction of periosteum and the formation of many abscesses, the limb is 
left riddled with sinuses leading down to the bare dead shaft. 

Sometimes, but not commonly, the neighbouring joints suppurate by 
direct extension from periosteum to capsule, and thence to synovial mem- 
brane ; most often, however, there is merely a serous effusion, the result of 
interference with circulation, or a slight degree of inflammation. 

Suppuration of a joint by direct extension might be expected to be most 
common in the case of the hip, where the epiphysial line lies within the 
joint, and this complication does sometimes occur ; it is not, however, common 
in our experience. Of twenty-three cases of acute periostitis under our care, 
the femur was affected alone in eight instances, the tibia was attacked in six 
cases (in two of these there was extension upwards to the femur), the 
humerus alone in two cases, the humerus and ulna in one, the radius in one, 
the ulna alone in one, the fibula in one, a rib in one, the ilium in one, and 
a metatarsal bone in one instance was inflamed. Five of these cases were 
supra-periosteal (parosteal), and in them no necrosis followed. There were 
five deaths, all from pyaemia, and all in sub-periosteal cases ; one- child had 
non-purulent pericarditis (proved by aspiration) and recovered. 

Usually the inflammation is limited by the attachment of the periosteum 
to the epiphysial line, and does not reach beyond this : sometimes it spreads 
in along this line and loosens the shaft from its epiphysis, or sets up an 
osteomyelitis. The same endosteal lesions may, of course, result from exten- 
sion inwards along the Haversian canals, but we think it is not the rule to 
find suppuration within the medulla, either epiphysial or diaphysial, as the 
result of acute periostitis. Quite apart from osteomyelitis, the whole shaft 
may necrose, probably because not only is the blood supply from the 

1 Periostitis and necrosis after typhoid do not occur till the patient is well of his fever 
{Paget, Path. Soc. Trans. 1884). Macnamara, however, quotes Affleck's cases of peri- 
ostitis in the third week of typhoid. We have seen a case of acute periostitis of the fibula 
following exposure to cold after influenza. 



Acute Periostitis 



639 



numerous small vessels entering the bone throughout its length cut off, but 
also because the nutrient artery itself, as well as the supply from the epi- 
physial zone, is lost. 1 

Mr. Macnamara, Air. Tubby,- and others believe that all these cases really 
begin as an inflammation of the epiphysial line, and that the mischief spreads 
downwards and upwards, both beneath the periosteum and in the medulla. 
That such a condition does occur their specimens prove, and we readily 
admit from our own experience, but that it is by 
any means the universal condition we cannot 
agree. 

If left to itself, then, and the patient survives, 
acute periostitis results in necrosis of a part 
, or the whole of the shaft of the long bone 
attacked ; subsequently new bone is thrown 
out by the surviving periosteum and surround- 
ing tissues, and the sequestra are inclosed in 
the sheath of this new bone, in which are 
cloaca? leading down to the dead part. 3 

Probably because the disease is a somewhat 
uncommon one, it is often mistaken, when it 
does occur, for erysipelas or rheumatism ; most 
of the cases of necrosis resulting from it are 
said to have followed one or other of these 
diseases. From erysipelas it is distinguished 
by the much greater pain in periostitis, by the 
absence of any defined line of redness, by the 
limitation of the disease and its evident relation 
to the shaft of a long bone, and, as soon as an 
incision is made, by the exposure of the bone 
shaft. 

There is, of course, no real resemblance to 
rheumatism of joints, inasmuch as the joints are 
only involved in very minor degree, so that this 
is a less excusable mistake. The disease most 
closely resembling it, especially the supra- 
periosteal form, is diffuse cellulitis ; this, how- 
ever, is usually more superficial and more 
widespread, not ceasing at the joints. In one 
case which we saw with Mr. Coates, of Man- 
chester, the mischief spread from tibia to knee, and beyond this upwards to 
the lower end of the femur — but this is very exceptional ; there was no 
suppuration in the femur. We have had another very similar case. 




Fig. 13S.— Acute Periostitis of the 
Femur, showing stripping off of 
periosteum and separation of the 
epiphysial junction. The lower 
part of the shaft has been re- 
moved post mortem. 



1 Vide Dent's able paper, Med. Chir. Trans. 188 r. Mr. Dent believes that the 
medulla may disintegrate without being inflamed at all. Vide also Makins and Abbott, 
St. Thomas s Hospital Reports, 1889. 

2 Brit. Med. Jour. May 9, 1891. 

5 Dr. Macewen, in a paper in the Annals of Surgery, expresses disbelief in the existence 
of any bone-forming power in the periosteum, and believes that all new bone is formed 
from bone itself. His views are, however, not at present accepted. 



640 Diseases of the Bones 

There is but one treatment of acute periostitis at all worthy of considera- 
tion, and that is free incisions down to the bone through the periosteum, as 
soon as the disease is diagnosed : each incision should be about one inch to 
two inches in length, and made in the long axis of the bone, care being taken, 
where practicable, to make the incisions not all on one side of the limb, 
though, of course, important vessels, &c. must be avoided. Several shorter 
incisions are better than one the whole length of the limb, as Mr. Holmes 
has pointed out. 

Bleeding is usually very free, and it may be necessary to plug the wounds 
for a few hours to arrest it ; the plugs should then be removed, drainage 
tubes inserted, and the wounds dressed every day or two, or oftener if there 
is much discharge. Should no pus be found at the time of incision, provided 
that it is certain that the bone has been laid bare, it may be taken as a 
proof that the disease is in its early stage, and the prospect is therefore 
better. In all cases, however, serum and flakes of lymph will be found, 
even if there is no pus, and there will usually be free suppuration in a short 
time. Too free exploration of the bone with the finger or probe, and too 
frequent or forcible syringing, are to be avoided, as tending to separate any 
still adhering periosteum, or to prevent adhesion after separation has oc- 
curred. The limb should be kept slightly raised, and stimulants, opium, 
and abundant nourishment given to the child. Should the fever not subside 
in a few hours, it is probable that some abscess has not been relieved, and a 
director should be passed round the bone, or a fresh incision made at any 
painful spot. In the tibia, for instance, where incisions can hardly be made 
at the back, pus may be lying beneath the periosteum at the back of the 
bone, bound down by muscular attachments. In spite of the au hority by 
which it is supported (Billroth), we cannot regard applications of nitrate of 
silver or iodine, or anything except free incision, as good treatment. 

Since such extensive necrosis and so much suppuration with liability to 
pyaemia often follow in these cases, it has been proposed to resect the 
affected bone at the time of incision, and this has been done by various 
surgeons. Since the periosteum is preserved, a new bone is developed, and, 
it is said, without shortening in cases where a second bone exists, as in the leg 
and forearm. 1 We cannot say we see any great advantage in this method, 
and it is impossible in any case to be sure how much of the bare bone will 
die — usually it is only a very small portion compared with the part exposed ; 
and, though we have at a later stage removed nearly the whole of the shaft 
of some of the long bones as sequestra, it is common to see quite small 
portions of dead bone as the result of most extensive stripping off of peri- 
osteum. We believe that much harm is often done by the practice, already 
alluded to, of passing in the finger, sweeping it all over the bone, and then 
remarking that the whole bone is bare ; of course it is, for the operator has 
just stripped off the remaining periosteal attachments. We think, therefore, 
that primary resection of the diaphysis is not to be recommended unless it 
is absolutely detached at each epiphysial junction and bare of periosteum 
throughout — a very rare condition. Neighbouring joints should not be 

1 Much shortening has, however, followed in some cases [vide Neve, Indian Med. 
Gas. April 1884, who records a case of an inch and a half shortening after removal of 
the upper half of the tibia ; also Holmes, Surg. Dis. of Children). 



Acute Periostitis 641 

incised unless they are pretty clearly suppurating, i.e. a slight degree of 
effusion does not mean suppuration. If the joint is full of fluid, and the 
skin over it is hot and its veins turgid, or if the swelling does not subside 
rapidly after incision of the periosteum, the joint should be opened or, if in 
doubt, aspirated ; if pus is found, a free incision and the insertion of a 
drainage tube are required. 

It must be very rarely that immediate amputation is demanded, even if 
joints are involved ; if there is no pyaemia, a large proportion of the cases 
do well, and if pyaemia exists already amputation will not usually succeed. 
If after free incisions the symptoms do not subside, and especially if pus 
escapes from the epiphysial line, there is probably suppurative osteo- 
myelitis ; the bone should then be exposed and trephined to give vent to the 
matter. 

Those surgeons who only admit the osteomyelitic origin of the disease 
advocate trephining the shaft of the bone close to the epiphysial junction as 
a drastic measure in all cases. It should certainly be done when there is 
mischief in the interior of the bone, and though it is certainly not always 
necessary it is better in these cases to do too much than too little. 

The time at which sequestra may be expected to be loose after the onset 
of the disease varies with the size of the bone and the extent of destruction : 
if the whole shaft dies the bone will probably be loose in a month or six 
weeks ; if only a part is necrosed it will vary from the time mentioned to 
many months, or, in the case of the femur, the bone, especially if the lower 
end is affected, may remain for years without being detached, and yet is so 
far devitalised that it acts as a foreign body and keeps up suppuration. This 
especially applies to periostitis attacking the popliteal surface of the femur, 
and holds good of chronic inflammation as well as acute. 

Xo absolute rule, then, can be laid down as to the time at which sequestra 
can be removed ; the sinuses should be explored with a probe from time to 
time, and if the dead part can be felt to be movable it should be cut down 
upon and taken away. If no loose bone can be felt, but the probe passes 
down through cloacae in the new bone to a sequestrum, the patient should 
be anaesthetised, the limb rendered bloodless, the sinuses laid open, the 
cloacae enlarged, and the sequestra examined : any that are loose should be 
taken away, and any distinctly dead but not loose bone may be cut away, 
but no doubtful bone should be disturbed — it may recover. The wounds are 
then plugged with iodoform gauze or lint, and daily dressed until they fill up 
or the sequestra become loose. It is very seldom that all the dead bone is 
removed at one operation ; usually small fragments either come away of 
themselves or have to be removed by later operations. In cleaning out the 
cavities in which sequestra lie great care should be taken not to break into 
joints or remove more new bone than is necessary. The delay in waiting 
for the separation of sequestra is not wasted time, for the new bone is mean- 
while consolidating, and the limb getting stronger. In subsequent dressings 
care must be taken to keep all the cavities well drained and syringed out, 
otherwise retention of discharges and detritus will give trouble. Unnecessary 
probing of sinuses is useless and harmful ; it is useless to be constantly 
feeling bone to see whether it is loose, for the process of separation is a 
slow one ; it is harmful, because broken granulations readily absorb septic 

T T 



642 Diseases of the Bones 

material, while sound ones are proof against it — moreover, it needlessly 
frightens a child. Where repair is very slow, and profuse discharge is 
wearing out the patient, it may be necessary to sacrifice doubtful bone 
for the sake of rapid healing, or in extreme cases, chiefly where there is 
destruction of a neighbouring joint and great prostration, even amputation 
may be required. 

C \SE. — T. B., aged 6£ years, was admitted April 22, 1881. Three weeks previously 
the boy fell down some steps and hurt his forehead and his shin, but seemed to get 
quite well. Two days before admission he complained of pain in the left thigh, hut ran 
about as usual. On the following morning he could not get up, had pain in the knee, 
and could not move the leg ; he was delirious during the night, with profuse sweating. 
On admission he was pale, dull, and heavy-looking ; respiration 48, temperature 106°, 
pulse 156, with low, muttering delirium. He was ordered four grains of quinine and 
brandy-and-egg mixture. The left thigh was swollen to nearly double its normal size 
from the top to the knee, and intensely painful. A short time after he came in, three free 
incisions were made through the periosteum down to the bone ; much sanious sero-pus 
and lymph escaped. The bone was quite bare. After the operation the temperature was 
104 , falling to 102-4°. There was great prostration. The temperature again rose to 
106 '6° at 11 P.M., when he died. 

Post-mortem. — There were recent pyaemic abscesses in the lungs, and the whole 
femur was bare from the neck to the lower epiphysis. No other disease was found. Vide 
fig- 138. 

Supra-periosteal abscess has the same general symptoms as the more 
serious conditions, but it is much less severe, for the reasons already men- 
tioned ; the pain and fever are less, though the swelling is often as great. 
On cutting into the abscess, and passing the finger in, the bone will be found 
still covered with the dense fibrous layer, and is consequently not bare. 
Necrosis seldom follows, or if it does it is limited both in extent and depth ; 
usually only a small scale of bone comes away. If this form of periostitis is, 
however, neglected, the deeper layer may slough, or the mischief spread 
through it, and more extensive necrosis may ensue. The diagnosis between 
the two conditions can generally be made by the less severity of the symptoms 
in the superficial variety. 

The immediate and later treatment is the same as that of the sub- 
periosteal form, i.e. free incisions at first, and subsequent removal of 
sequestra, should any necrosis occur. 

Case. — Supra-Periosteal Abscess of Thigh. — Mary Ann D., aged 13 years 2 months ; 
admitted December 24, 1882. Three weeks before admission she had pain about the 
lower part of the leg and walked lame ; the symptoms increased latterly, and the left 
thigh was noticed to be swollen and shining ; she had been getting thin and pale for two 
or three months previously ; no injury. On admission a large fluctuating swelling occu- 
pied the anterior and upper half of the left thigh, large veins ramified over the surface, 
there was a blush of redness over it, and some tenderness and pain ; an incision was made 
into the swelling, and a large quantity of pus escaped, which was in close contact with 
the bone, though the latter was doubtfully bare ; considerable bleeding took place into the 
abscess cavity, which stopped after a free counter-opening and more perfect drainage were 
employed ; she then steadily improved, and was discharged well on August 4. This 
case did not come under our care at first, and it was only at the second examination that 
we had an opportunity of exploring the bone ; at this time it was certainly not bare, a 
thin layer (deeper layer of periosteum) covering the bone. The constitutional disturbance, 
as usually occurs in the superficial periosteal abscess, was much less than in the sub- 
periosteal form, and no necrosis followed. 



Acute Periostitis 643 

A careful watch should be kept for the onset of pyaemia in all cases of 
acute periostitis ; it appears sometimes exceedingly rapidly. We have just 
mentioned a case of acute periostitis of the femur, which died with infarcts 
in the lungs and ecchymoses on the pleurae after an illness of altogether only 
two days, and another child died in the same way six days after an injury 
giving rise to periostitis of the fifth metatarsal bone. 

In some instances the periostitis is multiple at the first : these cases are 
no doubt pyaemic, and sometimes occur after a primary joint lesion ; thus we 
have seen acute suppuration in the ankle followed shortly by an abscess in 
the wrist, and a few days later by periostitis of the humerus and ulna, and by 
pneumonia. After death no other lesions than these were found. In another 
case, that of an infant six months old, periostitis of the tibia followed a suppurat- 
ing naevus of the scalp : the bone necrosed and gave way, a fracture result- 
ing ; the child died of pyaemia, sinking, as they so often do, quite suddenly. 

We have seen a case of pyaemic necrosis of the radius in which the lesion 
was close above the lower epiphysial line, but there was no shortening of the 
bone four or five years after. The patient was under the care of our friend 
Dr. Pooley, of Rochdale. 

The disease very rarely attacks any bones except the long bones of the 
limbs ; the tibia, femur, humerus, and ulna we have seen most commonly 
affected — sometimes the whole shaft, in other instances only a part, being 
laid bare. Occasionally the short and flat bones are attacked {vide T. Jones, 
' Diseases of Bones,' p. 90). Oven has recorded a case of the os calcis 
being the seat of the disease ; we have seen the ilium and a metatarsal bone 
attacked, and acute periositis of the skull has been met with. 

A case of acute periostitis of a vertebra is mentioned by Macnamara : 
Makins and Abbott have collected twenty-one cases of vertebral 'osteomyelitis,' 
as they prefer to call it (' Annals of Surgery, May 1896), and their article 
shows that any of the vertebrae may be attacked, and that either body or 
laminae or a transverse process may become inflamed. There is the greatest 
danger of extension to the spinal meninges, and pyaemia is very common 
(sixteen of the twenty-one cases died). The depth of the lesion and the 
obscurity of the symptoms have prevented the recognition of the condition 
in many instances. Free incision and perhaps removal of a lamina to set free 
pus within the spinal cord may be required. The lumbar spine is most 
commonly attacked Chipault, ' Le Gazettedes Hopitaux,' December 1896. 
Abstract in ' Medical Chronicle,' June 1887. Coutts also records a series of 
cases. 

Case. — Necrosis of Rib {traumatic). Empyema. — Wm. G., aged 10 years 7 months ; 
admitted November 20, 1881. Nineteen days before admission fell with his side against 
the kerb-stone ; two days later had much pain in the side, and swelling appeared next 
day ; had rigors, and was feverish and vomited on November 28. On admission, pale ; 
some dyspnoea, but not urgent ; anxious expression ; a soft fluctuating swelling over the 
lower part of the left side of the chest, rather larger than the palm of the hand ; the heart's 
impulse was two or three inches to the right of the sternum, and the whole of the left 
side of the chest was dull, and the respiratory sounds were distant, though audible ; a 
cyrtometer tracing showed distinct bulging of the left side ; the abscess was opened the 
same day, and a small quantity of thin pus escaped ; the pleural cavity was then opened 
and a pair of dressing forceps pushed into it between the ribs ; a large quantity of slightly 
turbid yellowish fluid was evacuated, the abscess cavity was clearly quite distinct from the 

T T 2 



6 4 4 



Diseases of the Bones 



pleura, and at that time- the pleuritic fluid was not purulent; the rib was bare, but nol 
fractured ; a tracheotomy tube was tied into the chest and the wound dressed antiseptically. 
All went well, and on December 3 a vulcanite tube was substituted for the silver tracheotomy 
tube. On the following day it was seen that for the first time the discharge was distinctly 
purulent, and it was considerable in amount ; the lower half of the left chest behind was 
still dull and tender to percussion, though in front the resonance was good. Up to this 
time there was still partial orthopncea ; a week later another abscess behind and a 
the first opening appeared, and, on incising it, bare bone was felt ; the dulness, &c. was 
clearing up. By the end of January 1882, the discharge from the chest had lessened and 
the dulness nearly disappeared. On February 2 an incision was made over the diseased 
rib, and about a third of it removed ; there was a good deal of new bone around the 
sequestrum ; the cavity left was plugged with a piece of sponge, which remained in place till 
March 6, when some of it was cut away ; several bleeding points in it then appeared, due 
to granulations which had sprouted into it and held it firmly in position ; at this time the 
left base was normal, except slight dulness. On March 13 antiseptics were discontinued ; 

on the 20th more of the sponge was cut away, and 
'at the end of the month the rest was removed ; 
it was found that it was impeding healing and 
causing eversion of the edges ; the sponge was 
filled with granulation tissue, which microscopically 
was seen to penetrate the unaltered sponge frame- 
work. The wound rapidly closed, and on May 5 
he was discharged almost well ; there was little 
if any retraction of the side, and the lung had 
apparently fully expanded. Here traumatic peri- 
ostitis of the rib led to abscess externally and 
serous effusion into the pleural cavity ; after the 
opening was made probably the suppuration in 
the chest cavity resulted from the communication 
with the external abscess. 




It is usually only in cases which are so 
severe as to be fatal that joint invasion or 
multiple bone lesions are found, but we 
have met with an instance in which the tibia 
was first attacked, then the knee joint by 
direct extension, the humerus, lower jaw and 
opposite femur all were involved, and yet 
the child completely recovered. 

Arrest of growth from destruction or 
synostosis of the epiphysial line may result 1 ; 
or, on the other hand, there may be over- 
growth from persistent hyperemia of the 
limb, as the result of the subsequent irri- 
tation caused by sequestra (fig. 139). This 
overgrowth may, as seen in the figure, cause distortion from one bone of the 
limb outgrowing the other. 2 Occasionally relapses occur many years after 
the original disease has subsided, and abscesses form, and sequestra are 

1 J. H. Morgan has detailed a case in the Brit. Med. Jour., September 1, 1883. The 
humerus was the bone affected. Vide also Tubby, Lancet, June 6, 1891. 

2 Birkett has recorded a case of overgrowth of a limb after injury to the patella in a 
boy of eight years {Path. Soc. Trans, vol. xviii.) ; vide also Edmunds, Path. Soc. Trans- 
1885. A case of B. Pollard's, described as hypertrophied callus, is perhaps of the same 
nature. 



Fig. 139. — Shows Overgrowth of the 
Bones of the Right Leg, especially 
the Tibia, after Necrosis. (Dr. 
Massiah's case.) 



Acute Periostitis 645 

separated in middle life. We have several times met with these cases of 
' relapsed necrosis.' 

Where the periosteum has extensively sloughed, or where the bone has 
been fractured, a short, weak limb may result from deficient development of 
new bone ; these fractures sometimes remain ununited, and may require 
resection and wiring. 

Case. — Non-Union of Tibia after Fracture as Result of Necrosis. — Female, age 
4 years 5 months ; five months ago left hospital, after sequestrotomy, in a plaster bandage ; 
no union occurred, and limb was useless and quite movable, though not flail-like ; incision 
made down upon ends of bone, which were much atrophied : surfaces refreshed and wired 
together by one silver suture, which was fixed to buttons on surface of wound ; ultimately 
firm union occurred, and child could bear her weight upon her leg and walk well. 

As the accounts of different writers on the subject of acute bone inflamma- 
tion are somewhat conflicting, and give rise to confusion, the following 
statement of how the different lesions may arise will perhaps be of service 
to those less familiar with bone diseases. 

Acute inflammation of bone may begin as : 

A. Periostitis. 

1. Sub-periosteal. 

2. Supra-periosteal or Parosteal. 

B. Osteomyelitis. 

1. Epiphysitis, i.e. disease beginning in the cancellous tissue of the 

epiphysis. 

2. Inflammation of the medulla of the shaft (diaphysitis). 

3. Inflammation beginning in the epiphysial line, often called 

epiphysitis also. 

4. ' Juxta epiphysary diaphysitis,' or inflammation of the end of the 

diaphysis close to the epiphysial cartilage. 

Inflammation arising in any of these ways may give rise to the other 
forms of lesion ; e.g. sub-periosteal abscess may spread along the epiphysial 
line and cause suppuration in the medulla of the shaft, or inflammation of 
the medulla may spread outwards and cause periostitis. As a rule, however, 
careful clinical observation will enable an accurate opinion to be given of 
the primary seat of the mischief. We are becoming strongly of opinion 
that it is common for tuberculosis to be grafted on to cases of acute inflamma- 
tion of bone, i.e. we believe that many of these cases which after the acute 
symptoms have subsided run a chronic course, are really tubercular, and it is 
possible that in some at least the process may have been acute tuberculosis, 
or at least a mixed infection from the first. 

Acute Osteomyelitis. — Acute diffuse infective osteomyelitis occurs 
as a result of amputations or resections, but this is a rare condition ; it is 
said to be more common in hot climates. The disease is, however, here 
most often met with as a result of extension to the medulla of inflammation 
beginning in the epiphysis or epiphysial line or end of the diaphysis, or of acute 
periostitis, and occasionally occurs as a primary condition. Mr. Macnamara, 
and with him some of the continental surgeons as already mentioned, 
believe that the affection already described as acute periostitis is really acute 
osteomyelitis ; this, however, is, not always the case, since if it were so com- 
plete recovery in these cases without extensive necrosis would not be nearly 



646 Diseases of the Bones 

so common as it is. Moreover, in cases of acute periostitis dying of pyaemia, 
sections of the bone have shown an entire absence of osteomyelitis in some 
instances. 

The characteristic symptoms, in a case where acute osteomyelitis follows 
amputation, are swelling and subsequent suppuration of the medulla, retrac- 
tion of the periosteum and soft parts, so that the bone is left bare, and 
diffuse swelling" of the limb. Pyaemia usually rapidly ensues, and in many 
cases death speedily results. Amputation at the joint above has been 
usually said to be the only successful method of treatment, but the plan 
introduced of scraping out the entire contents of the medullary canal, as 
advocated by Mr. Keetley and others, is well worthy of adoption, and has 
proved successful in several instances ; our colleague, Mr. T. Jones, among 
others, has had good results from this method. 

Where acute diffuse osteomyelitis occurs as a sequel to epiphysitis or 
periostitis, or is the primary lesion, the shaft of the affected bone should be 
freely opened with trephine or chisel, and a similar treatment adopted. The 
existence of this disease may be suspected as already pointed out, when the 
severe constitutional symptoms and pain do not subside after freely incising 
the periosteum or opening up an epiphysial abscess : swelling and tenderness 
at one or more points in the shaft, or diffuse bony swelling without any col- 
lection of fluid beneath the periosteum, will indicate the presence of pus in 
the medulla. For an excellent account of the whole question, vide ' Diseases 
of the Bones/ by T. Jones, 1887. 

Acute Epiphysitis. — Acute circumscribed osteomyelitis or acute epiphy- 
sitis is a more common condition ; it consists in a localised inflammation 
attacking the cancellous tissue of an epiphysis or the immediate neighbour- 
hood of the epiphysial line. The disease nearly always goes on to suppura- 
tion, and on examination a cavity will be found containing pus, or in some 
cases sequestra. Acute epiphysitis may occur in children of any age : for 
instance, most cases of 'acute suppurative arthritis of infants' are typical 
examples of this disease {vide p. 670) ; in other, though much rarer, instances 
older children are attacked. 1 

If left to itself, the pus finds its way either into the adjacent joint or along 
the epiphysial line to the surface (the epiphysis may in this way become 
detached from the shaft), or down the medulla of the shaft, giving rise to 
acute diffuse osteomyelitis. The disease may follow an injury or exposure, or 
one of the exanthems, or, according to Mr. Greig Smith, may arise from 
lymphatic infection of the bone marrow. It most commonly attacks the 
head of the femur, the upper end of the tibia, or the lower end of the femur, 
less often the extremities of other long bones. Some of the cases of acute 
disease of the hip, elbow, shoulder, and ankle, apart from ' acute suppurative 
arthritis of infants,' are really also of this nature. 

The lesion is marked by early fever and much pain, 2 of gnawing, tooth- 
ache-like character, followed, after a longer or shorter time, according to 
the age of the patient and the amount of resistance to the exit of the pus, 
by swelling of the bone coverings and effusion into the adjacent joint, which 

1 Vide Abstracts of Cases treated at Children's Hospital, Pendlebury, 1882. 

2 In the infantile cases we have, of course, no means of knowing the kind of pain, but 
usually it is evidently severe. 



Acute Epiphysitis 647 

is usually kept fixed in the position of least tension. We have, however, 
seen the knee strained to its utmost degree of flexion, far beyond the point 
of least tension ; thus showing at once that the lesion could not be intra- 
articular. 

The pain is usually agonising, and the failure of health very rapid. Deep 
pressure in the earlier stages, and any touch of the limb when the pus is 
approaching the surface, is exceedingly painful. Local heat is usually only 
appreciable in the later stages ; increased pulsation in the main artery of the 
limb may be found. In infantile arthritis (acute suppurative arthritis) the 
symptoms are sometimes subacute. The diagnosis is made by careful 
exclusion of joint lesions (by lack of marked effusion, &c), where the joint is 
still free, and attention to the history of the pain and swelling, so as to dis- 
tinguish the case from periostitis, though, of course as pointed out by 
Macnamara and others, and as already described, epiphysitis may give rise 
to sub-periosteal abscess and necrosis as well as to intra-articular abscess ; 
pain on deep pressure in the absence of joint disease is a characteristic 
feature. Rheumatism and rickety pain are readily distinguished by the 
strict localisation of the suffering. In the infantile cases the joint is usually 
involved by the time the child is brought. 

Case. — Abscess in the Head of the Tibia. — Wm. Hy. D. , age 9 years; admitted 
December 30, 1881. Had pain in the leg for two months ; worse for five days ; no fur- 
ther history. On admission he was pale, ill, and anxious. Temperature 103 '8° ; there 
was intense pain in the right knee, which was flexed to its fullest extent ; there was no 
effusion in the joint, and the outlines of the condyles were distinct through the tightly 
stretched skin. Over the head of the tibia and the upper third of the leg there was con- 
siderable swelling, most marked over the inner tuberosity of the tibia, where also the 
tenderness was greatest ; no fluctuation ; under chloroform an incision was made over the 
inner tuberosity, and the soft parts found infiltrated with inflammatory products, but no 
pus ; a chink indicating the line of union of epiphysis and diaphysis was seen, and on 
gouging away some bone about 5 ss. of thick sanious pus escaped ; no distinct cavity 
was found ; operation antiseptic ; a tube was put into the opening in the bone ; one hour 
after the temperature was 102 - 6°. He had pain on several evenings subsequently, and 
there was but little non-purulent discharge for two days, when several drachms of pus were 
discharged. On January 5, as the joint was swollen, it was aspirated, and a small quan- 
tity of turbid sanious fluid withdrawn and an ice bag applied ; he had no pain afterwards, 
but en the 12th the joint began again to swell, and on the 15th was distended, and in- 
cisions were made into it, discharging fluid, at first flaky, but serous, and subsequently 
more nearly purulent. On February 9 the drainage tubes were removed and all was going 
on well, the wounds in the joint being superficial, though bone could be felt through the 
opening into the tibia ; the limb had been kept fixed. On the 23rd the joint was forcibly 
flexed and several adhesions broken down ; considerable swelling followed ; the joint 
shortly settled down again. March 3, a small sequestrum was removed from the tibia as 
well as a good deal of caseous material. April 3, the limb was put up in plaster of Paris, 
and the boy sent oiit on the 5th. He attended as an out-patient subsequently ; several 
small bits of bone came away, but the wound finally closed, and he has now, February 
1883, a sound limb with a fully movable knee, though a little thickening still remains. 

The treatment of acute epiphysitis consists in early and free incision 
down to the bone ; if matter is met with, this is usually sufficient, but, should 
the pus not have reached the surface, an opening must be at once made into 
the bone and the abscess emptied, any sequestra found being removed. In 
any doubtful case it is far better 10 explore the bone than to run the risk of 
the abscess bursting into the adjacent joint. Should the joint be already 



648 Diseases of the Bones 

involved, as it almost always is in the acute epiphysitis of infants, it must be 
freely opened and drained. For a more detailed account of infantile epiphy- 
sitis, see the chapter on DISEASES OF the Joints, p. 670. Messrs. Pick 
and Page have recently called attention again to these cases which have 
been described above, and discussed both in former editions of this book 
and elsewhere. 

Should the mischief have spread to the medulla of the shaft, the diaphysis 
should be exposed and trephined at one or more spots to give vent to the 
pus, and the whole medullary cavity should be scraped out, washed, and 
drained ; failing this, amputation is the last resource. For some good cases 
illustrating this treatment, vide T. Jones on ' Diseases of the Bones,' 1887, 
and 'Medical Chronicle,' Dec. 1886. 

A condition known as ' Growing- Fever ' is sometimes met with, usually 
in children of from seven to fifteen years, though occasionally at both earlier 
and later ages. The main features are pain in the region of the epiphysial 
lines, rapid growth and sometimes fever, with considerable constitutional 
disturbance. Usually the symptoms pass off without any bad result, but in 
rare cases osteomyelitis may be set up, and the development of exostoses 
about the epiphysial lines has also been noticed after the occur- 
rence of 'growing fever' {vide 'British Medical Journal,' April 14, 1888, 
p. 820). 

Chronic Periostitis. — Periostitis of less severity, and less rapid in pro- 
gress, is common enough, and the subacute cases are better classed with the 
chronic than with the acute, inasmuch as they are more like the former 
than the latter in their results. Subacute or chronic periostitis occurs in 
children as the result of injury, as a pyasmic condition, or as the sequela of 
an exanthem — probably these two sets of cases are very closely allied, if not 
identical ; or it may be caused by syphilis or tubercle. Whichever of these 
is the cause in any individual case, suppuration often takes place except in 
traumatic and in many of the syphilitic cases. Since the process is a slow 
one, it is usually impossible to say whether the lesion began as a sub- or 
supra-periosteal inflammation ; perhaps the whole thickness of the membrane 
is involved at once, or else, as the bone is usually more or less deeply impli- 
cated, the lesion is sub-periosteal in origin. 

The disease is characterised by local or diffused thickening of the bone 
in its early stages ; the swelling is tender, painful at times, but usually, unless 
in subacute cases, there is no implication of the skin. Later on, the swelling, 
if left to itself, either subsides or softens down, and abscesses form in one or 
more spots : on incising these the bone is found bare and rough, with perhaps 
small scale-like exfoliations, or in other cases, to be described presently, 
more extensive lesions. The periosteum is sometimes four or five times its 
usual thickness, and readily peels off the bone, while in old cases there is 
often some rough spiny deposit of new bone developed around the centre of 
disease. In traumatic cases in healthy subjects the thickening may subside 
altogether without any trouble or suppuration, or there may be sufficient new 
bone formation to cause swelling lasting for months or years without any 
other symptoms. 

In tuberculous children the swelling (' strumous periosteal node') usually 
slowly increases, often painlessly, though by no means always so ; suppura- 



Clironic Periostitis 



649 



tion finally occurs and matter is discharged, or in rarer instances the in- 
flammation subsides. Generally in the tuberculous cases periostitis is either 
the result of, or itself leads on to, osteomyelitis. (Superficial or central 
caries.) 

Exanthematous periostitis is found usually in wasted and feeble children, 
either in the course of, or as a sequel to, one of the specific fevers ; there is 
often much suppuration, with but little pain or disturbance, and a limb is 
found occasionally to be little more than a flabby bag of pus, without any pain 
and without much fever. The child lies wasted and haggard, with rough scaly 
skin, and offensive smell, the hair harsh and often thin, and the veins showing 
distinctly through the thin, fatless 
skin. The chronic pyasmic cases so 
exactly resemble these that it is 
probable that many of the exan- 
thematous forms are really pyaemic. 
A fair number of such children 
recover, others gradually sink of 
exhaustion or some intercurrent 
pneumonia or diarrhoea. Much 
less severe cases are also met with, 
in which chronic periostitis occurs 
affecting only a small part of a bone 
— it may be any bone — and either 
subsiding or giving rise to only local 
necrosis ; the ribs and tibiae and 
upper end of the femur seem to 
be specially often attacked after 
typhoid fever. For an excellent 
account of these diseases, vide T. 
Jones on ' Diseases of the Bones,' 
1887, p. 40 ; vide also chapter on 
Spinal Disease, infra, p. 713, for 
a case of necrosis of a spinous 
process. 

Congenital syphilitic periostitis 
is usually multiple, and occurs 
rarely during the first year or two 
of life, being commonest from 

about the 5th to the 15th year. It is, as Hutchinson has pointed out, less 
amenable to antisyphilitic treatment than the periostitis of acquired syphilis, 
and according to him is common in the upper limbs ; in our experience 
symmetrical periostitis of the shafts of the tibiae (' syphilitic nodes ') is far 
the commonest form, and in some cases it breaks down and large ulcers 
form on the surface. The amount of thickening may be enormous, as in 
fig. 140. 

Case. — Chronic Syphilitic Periostitis of Tibia. — Lilian G. , age 12 years; admitted 
November 19, 1884. Mother had three miscarriages as the result of her three first preg- 
nancies. Patient when born had an eruption about the buttocks , sores round the mouth, 
and snuffles ; improved at six months old, and has gone on well since, except for a sore 




f 



140. — Congenital Syphilitic Disease cf both 
ibiae (periosteal and endosteal). This figure, 
from a patient of our own, is reproduced from 
Mr. Jones's book. 



650 Diseases of the Bones 

eye. Duration, three years; following a slight kick ; noswelling till a month later; much 
pain ever since ; has been under treatment (antisyphilitic) as an out-patient for some con- 
siderable time. On admission, healthy-looking girl ; teeth normal ; no obvious sigl 
syphilis ; the right tibia is much thickened, and apparently bowed antero-posteriorly ; no 

fluctuation ; the most tender spot is on the front of the lower part of the middle third ; the 
swelling involves nearly the whole shaft ; no fever. November 27, tibia trephined at its 
most painful spot ; periosteum much thickened ; the bone was much sclerosed and the 
medullary cavity reduced to a narrow channel ; no pus and no cavity found. The reflected 
periosteum was stitched together with catgut and tube inserted. Operation antiseptic. 
All went well ; she was discharged on December 17 ; there was no further pain, and when 
seen as an out-patient, February 1885, she was sound and well, and free from pain. 

Cask. — Syphilitic Periostitis of Tibia. — John Wm. A., age 6 years. Xo tubercular 
history ; one of the children died of convulsions at seven weeks — it had snuffles ; three 
other children living ; no miscarriages. Child healthy at birth, weakly since three 
years old ; the leg has been tender for six months, but no swelling was noticed till 
four days ago ; no pain unless touched. On admission, pale, unhealthy child ; has 
remains of double interstitial keratitis and scars at the angle of the mouth ; the upper 
milk incisors have gone, lower incisors small and ill-formed ; there is thickening, forming 
a prominent swelling in the middle of both tibias, tender but not red. The tenderness 
disappeared quickly under treatment (antisyphilitic), the swelling remaining much the 
same. 

Less frequently the upper end of the tibia is involved ; in such cases 
there is not rarely effusion into the knee, not merely passive, but an actual 
serous synovitis. Other evidence of congenital syphilis is in our experience 
almost always to be found, though it is not always obvious. One tibia 
alone may be affected and the disease may be progressive in later life though 
due to congenital syphilis. Occasionally the evidence of syphilis may be 
wanting. The pain is often severe, though sometimes it is almost absent. 1 
Macnamara believes that the syphilitic telostitis of infants (see chapter on 
Congenital Syphilis) is due to interference with nutrition at the epi- 
physial line from pressure of new-formed periosteal deposit around, and that 
the telostitis is not inflammatory.- Arrest of growth may result just as in 
the case of older children who are attacked by syphilitic epiphysitis 3 {vide 
Epiphysitis). The palate and bones of the face are not rarely destroyed by 
congenital syphilis, but this occurs in a late stage of the disease {vide 
fig. 91) ; the nasal bones are, of course, early affected, and the deformity 
resulting gives rise to one of the characteristic features of inherited syphilis. 
The evidence afforded by thickening of the bone, with tenderness on deep 
pressure and aching pain, serves to distinguish periostitis generally from 
any more superficial lesion, while the onset of swelling and pain simul- 
taneously points to the existence of periostitis rather than osteomyelitis, 
though either, it must be remembered, may give rise to the other. New 
growths are to be distinguished by their greater rarity, their greater promi- 
nence, with often bosses and a well-defined margin, and local patches of 
softening, as well as by their situation, which is usually at the ends of the 
bones ; hence they are more likely to be mistaken for osteomyelitis than for 
periostitis. 

The tuberculous and syphilitic lesions are nearly always accompanied by 

1 Mr. Moullin has written a good paper on this subject in the Brit. Med. Jour. 1884, p. 52. 
- Brit. Med. Jour. July 5, 1884. 5 Hutchinson, London Hospital Reports, vol. ii. 



Chronic Periostitis 651 

other evidences of their respective diseases, such as tuberculous glands or 
ulccrs, a family history of tubercle, or, on the other hand, syphilitic lesions 
of the eyes, teeth, &C. 1 

There is difficulty sometimes in distinguishing the lesions of bone due 
to congenital syphilis from those dependent upon tuberculosis, though we 
are not inclined to think that the mistake is so often made as Fournier 2 
would have us suppose. As already mentioned, the tibia is (as Fournier 
also points out) the bone most commonly affected by the syphilitic lesions, 
and the long bones are more often attacked than the short or flat bones, 
with, perhaps, the exception of the skull, while the diaphysis is more liable 
to be attacked by syphilis than the epiphyses. New bone formation, severe 
pain, little tendency to suppuration, though occasionally abscess and 
necrosis do occur, and evidences of syphilis from the history or presence of 
other syphilitic lesions, are the principal features of the one group, while 
the tuberculous cases are characterised by absence of any new bone forma- 
tion, caries occurring rather than necrosis, by early suppuration, freedom 
from pain, and the other features already pointed out. The effects of treat- 
ment by iodide of potassium will give confirmatory evidence. In any case 
of doubt antisyphilitic treatment should be given a fair trial, it being 
remembered that children bear, and often require, large doses of iodide 
(gr. x.-xx.) to obtain good results. It must not be forgotten that congenital 
syphilitic lesions may co-exist with tuberculous disease, and in such cases 
affections apparently tuberculous will not yield until antisyphilitic treatment 
is employed. 

Nearly all the varieties of periostitis are found chiefly in the long 
bones, though similar lesions may be met with elsewhere, as in the jaws, 
&c. ; vide chapter on Diseases of the Mouth, and also the chapter on 
Joints. 

Treatment. — In early stages of the disease, if the leg is affected the child 
should be kept in bed with a splint on. Cod liver oil and iron should be 
given in the tuberculous, hydrarg. c. creta or iodide of potassium in the 
syphilitic cases ; the former in children one or two years old, and a com- 
bination of the mercury and iodide in older cases being the best treatment. 
Where the arm is affected, a splint should be applied and the child allowed 
to be up, unless any subacute mischief is going on. Simple traumatic cases 
require rest and the application of soothing lotions, such as lead, with or 
without spirit or opium, or the application of belladonna diluted with glycerine 
or vaseline ; in some cases good is done by rubbing in mercurial ointment, 
or better, ung. hydrarg. oleat. 5 or 10 per ct., or keeping it applied over the 
swelling. Some surgeons have faith in the application of iodine ; a blister 
is sometimes undoubtedly of use in relieving pain. If after a fair trial of 
some weeks no good result has been obtained by these means, and pain 
still persists, or, of course, earlier than this if suppuration occurs, an incision 

1 Dr. Goodhart has met with a remarkable case of bone disease in a child a year old, 
which was thought to bear relation to osteitis deformans, but was probably syphilitic ; 
there were tenderness, softening, and diffused thickening of the bone ; rickets co-existed. — 
Path. Soc. Trans, vol. xxxiv. 

2 La Syphilis Hdreditaire Tardive. Paris, 1886. To this work we must refer for an 
elaborate account of the later lesions of hereditary syphilis. 



652 Diseases of the Bones 

should be made down upon the bone through the periosteum ; if pus is 
found, or any superficial necrosis, the case is to be treated on ordinary 
principles ; if after this the pain is not relieved or returns, it may be taken 
for certain that osteomyelitis exists, either as a primary or secondary con- 
dition ; and this should specially be borne in mind in tuberculous cases in 
which osteomyelitis is much more commonly the primary lesion in Ion- 
bones. If then there is evidence of osteomyelitis, further measures will be 
required {vide infra). 

Occasionally in syphilitic cases no absorption takes place under mercurial 
or iodide treatment ; if the pain persists, the bone should be cut down upon 
and, if necessary, trephined or gouged, so as to open up the sclerosed bone 
and give vent to any pent-up material (cf. case, p. 649, antea). In cases of 
syphilitic necrosis of the bones of the face or palate a plastic operation may 
be required, but this should not be attempted until the destructive process 
has entirely ceased. Where the whole hard palate has been destroyed an 
obturator may be necessary. We have seen a case where, after ulceration 
of the palate and pharynx, the soft palate became adherent to the pharyngeal 
wall, and the obstruction to the nose thus produced caused so much trouble 
that excision of part of the soft palate became necessary. ' Periostitis 
albuminosa' is a name given to a form of periostitis in which there is 
effusion of non-purulent fluid beneath the periosteum. There may or may 
not be necrosis. There is no hard-and-fast line to be drawn between these 
cases and chronic purulent periostitis ; the exact nature of the effusion may 
in our experience vary from serum to solid lymph on the one hand or pus 
on the other ; a similar variation occurs in the case of the effusion in central 
inflammation. We have found the medulla replaced by masses of curd-like 
lymph with little or no pus. 

Chronic Circumscribed Osteomyelitis. — Where chronic osteomyelitis 
is localised, as, for instance, sometimes in the epiphysial extremities of the 
long bones, an abscess may result, with or without necrosis ; the symptoms 
are those of acute epiphysitis, already described, only less severe, and the 
onset of the disease is slower and more insidious. In non-tuberculous cases 
there is often much sclerosis of bone around the abscess cavity, and the 
disease may go on for years without any attempt at reaching the surface. 
In other instances the extension of the inflammation to the surface is marked 
by slight and slowly increasing thickening of the periosteum, "so that the 
diameter of the bone is somewhat increased, and the tissues over it may be 
slightly cedematous. The characteristic aching, gnawing pain, especially at 
night, is sometimes well marked, but in children more often there is com- 
paratively little pain, and the pus soon finds its way to the surface— both 
these facts being due, no doubt, to the less resisting nature of the softer 
bones of children. Hence the more typical features of chronic circumscribed 
abscess of bone are comparatively seldom seen in young children, but are 
most marked in young adults. Moreover, in children the distinction between 
circumscribed and diffuse osteomyelitis is also less defined ; though sclerosis 
of the walls of the cavity does sometimes occur, it is less frequent in children, 
and the inflammation is more apt to become diffuse. The attacks of pain 
may be intermittent, so that for weeks or months there is little sign of any- 
thing wrong, and then all the symptoms reappear. 



C/ironic Circumscribed Osteomyelitis 



653 



Case. — Epiphysitis of both Femora, &c. — John \V. , age 6; admitted April 12, 1884. 
Always delicate ; for eighteen months past had abscesses ; twelve months ago had dropsy ; 
eight months ago had measles ; four months ago knee swelled painlessly, was poulticed 
and opened. On admission, delicate child ; abscess scars about neck, &c. Sinus over 
left upper arm leading to bare bone. Just above right knee is a sinus, and two more in 
popliteal space, another below the knee ; at lower third of leg is a large abscess ; sinuses 
also round left knee. 18th, abscesses on leg and knee opened ; 21st, sent out for a 
while. Readmitted May 19. June 3, explored, and bare bone felt at back of right knee 
and in arm. June 11, under chloroform. Left thigh explored through incision on outer 
side ; no bare bone felt, and posterior triangular space was healthy, but bone was enlarged, 
so a circular opening was made with 
a gouge, and deep in the centre of the 
bone was found a cavity containing 
pus and pus-infiltrated bone ; on clear- 
ing out this a cavity the size of the 
top of the thumb was left with scle- 
rosed walls. On the right side bare 
bone was felt behind and above the 
internal condyle ; a precisely similar 
operation was done and just the same 
condition found, together with several 
small hard sequestra. This cavity 
communicated by a circuitous course 
with the sinus on the outer side ; this 
was only found out by injecting lotion. 
A small sequestrum was also removed 
from the humerus. Wounds syringed 
out with chloride of zinc and filled 
with iodoform. Some cellulitis, &c, 
followed, but he did fairly well up to 
a certain point, and was discharged 
July 31. He was subsequently re- 
admitted with the disease in the right 
thigh extending, and was still under 
treatment in 1892. He is now lost 
sight of. 

Abscess in bone is not limited 
to childhood, but very frequently 
begins before puberty, though 
many of these patients do not 
come under treatment until the 
disease is of long standing. 
Though most commonly met 
with in the cancellous tissue of 
the extremities of the long bones, abscess may also occur in the shaft, and 
we have more than once had to trephine for circumscribed abscess in the 
middle of the shaft (of the femur or tibia) occurring many years after an 
attack of acute periostitis. Inflammation of bone due to typhoid may 
become active after a quiescent period of twenty or more years. 

Treat7nent. — As in acute periostitis, there is but one thing to be done in 
these cases. A free incision should at once be made down upon the bone, 
and, either with a gouge or trephine, a hole made into the cancellous tissue 
until the abscess is reached. Before operating the exact spot of greatest 
tenderness should be marked, and this is to be the centre of the incision. 




Fig. 141. — Epiphysitis of the upper end of the right Hu- 
merus, with softening and relaxation of the ligaments of 
the Shoulder Joint. The joint cavity was not involved. 



654 Diseases of the Bones 

We have derived great help from this precaution in finding a small abscess 
in bone. Some surgeons prefer to do linear osteotomy, i.e. saw across the 
epiphysis with a fine saw, and thus open up the abscess ; but this plan is in 
no way better than the other. The bone is usually found soft, red, and 
rarefied ; often only a drop or two of pus will escape, and this may be 
overlooked. Even if the abscess is not found, relief is almost sure to 
follow, and pus will be discharged in a day or two ; at the same time, if 
no abscess is found, careful exploration should be made in every direction 
for the matter, to diminish the risk of its opening into the joint. Should a 
sequestrum be found, it will be of course removed, and the cavity should be 
well scraped out and drained ; should the adjacent joint be involved, it 
must be treated like any other suppurating joint. 1 

Chronic Diffuse Osteomyelitis. — This disease is met with chiefly as a 
tuberculous or as a pyaemic condition ; it may result from extension from a 
primary periostitis, or originate in the medulla, perhaps most often beginning 
in the epiphysial line. It is a matter of extreme difficulty, and sometimes 
impossible, to be sure whether a given lesion has begun as a local periostitis, 
spreading afterwards to the epiphysial line, or whether the epiphysial lesion 
is primary and the periostitis secondary. 

The tuberculous disease in a well-marked case is a remarkable lesion ; the 
child has perhaps a history of some long-continued bone trouble coming on 
after measles or other illness, or after an injury ; external examination shows 
thickening of a large part of a long bone, with a sinus leading down to a 
cavity in the shaft. At first sight it appears that the case is one in which 
either the periostitis is the main lesion, or a small localised central inflamma- 
tion has reached the surface and then spread along the periosteum ; but on 
cutting down upon the cavity, and clearing it out, a small sequestrum, 
infiltrated with pus, and greenish-yellow in colour, is removed. Instead, 
then, of finding the walls of this cavity formed of healthy but sclerosed bone, 
they are soft and also infiltrated with pus, showing the same greenish colour 
as the sequestrum. There is no sharp line of demarcation between this 
green bone and the surrounding shaft, but patches of rarefied pale bone are 
seen in parts. On attempting to gouge away the diseased tissue it will 
often be found to extend throughout a great part of the shaft, and perhaps 
several inches of cancellous tissue are thus removed before living bone is 
reached. When all has been removed the cavity slowly fills up; leaving a 
sinus or two. Some months after, on exploring these sinuses, a similar 
condition is found ; the purulent infiltration has again gone on spreading, 
and in time it may reach an adjacent joint and set up disease there. In such 
cases the compact tissue is usually healthy in appearance, though sometimes 
it is perforated, and there is generally some, but not always great, periosteal 
thickening. In other instances where the changes have been rather more 
active, the diseased part becomes isolated and sequestra are thrown off 
('chronic circumscribed osteomyelitis,' ' central necrosis'). Sometimes the 
compact tissue also dies (' total necrosis '). Though this disease mostly 
commonly affects the long bones, it may, as already pointed out, attack the 
jaw ; here even the new bone may become infiltrated, and die as fast as it 

1 The subject of acute suppurative arthritis in infants (acute epiphysitis) is treated more 
specially under Diseases of the Joints. 



C J ironic Diffuse Osteomyelitis 655 

is formed ; it is, however, doubtful whether this condition in the case of the 
jaw is tuberculous {vide Diseases of the Alimentary Canal). 

Case. — Alveolar Abscess, Necrosis of J ati\ — Joseph P., age 6 years ; admitted May 31, 
1884. Fairly healthy till four months ago, when he had toothache ; tooth extracted, but 
swelling did not subside. On admission, much swelling over right side of lower jaw. 
From socket of first lower molar, which is gone, pus and granulation tissue exude. 
June 4, alveolus cleared out ; some small pieces of bone and a rudimentary permanent 
tooth removed. Discharged June 4. Readmitted June 23, with more pain, swelling, and 
discharge ; external incision made and pus let out. June 26, swelling, &c. increased ; a 
large sequestrum removed from inside the mouth, and several more through the external 
opening ; these sequestra were soft, foetid, and pus-infiltrated, and formed part of the 
horizontal and ascending rami throughout their entire thickness ; the cavity left extended 
nearly up to the joint ; some new bone had been formed and died subsequently. July 9, 
discharged much relieved. 

The scapula, clavicle, ribs, pelvis and sternum, and facial bones are also 
sometimes attacked, and disease of adjacent joints may occur by extension. 
Though the malar and upper jaw bones are often affected, we have seldom 
seen any of the bones of the vault of the skull attacked, except the temporal, 
and this has been a result of disease of the ear. The occipital we have 
once seen perforated by tuberculous disease, and in the same child the 
frontal bone was carious. The process is essentially alike in all these cases. 
The sequestra are generally soft, and in some cases the pus decomposes and 
they become foetid, but this is not by any means generally so in the limb 
bones. 

A similar condition is found in the epiphyses of the long bones without 
the shaft being involved ; sometimes a whole epiphysial nucleus will die 
and shell out as a sequestrum. We have met with the same condition in the 
patella, leading to destruction of the knee joint. 1 

Case. — Necrosis of the Patella. Disease of Knee Joint. — John R. , age j\ years ; ad- 
mitted July 7, 1882. Ten weeks ago had a blow on the left knee, which became painful a 
week later. On July 2 it began to discharge ; his health had been failing since an attack 
of whooping cough eighteen months ago ; phthisis in family. On admission, a fluc- 
tuating swelling mapping out the left knee joint, a little redness and venous turgidity ; a 
half-closed sinus lay over the ligt. patellae ; limb nearly straight ; no pain. July 18, sinus 
explored ; it was found to lead upwards into a cavity in the patella, from which a seques- 
trum, the size of a damson stone, was removed. The joint was incised on each side, and 
a free communication found to exist between the joint and the sinus through the patella ; 
coagulated lymph and serous fluid escaped from the joint ; operation antiseptic. August 17, 
has done well, and line of incision was healed except at entry of drainage tube ; very 
little discharge ; general condition good ; no fever since operation. August 29, dis- 
charged in a back splint ; . readmitted in October ; wounds healed ; passive movement 
attempted, but adhesions found to be strong and universal, not giving any hopes of 
a movable joint, so he was fixed in a back splint with plaster of Paris, and sent out 
November 15. 

In this chronic osteomyelitis, an epiphysial line acts only as an imperfect 
barrier, and, where the disease begins in it, it usually spreads both upwards 
towards the joint and downwards into the shaft. When the whole epiphysis 
is involved, the articular cartilage may be exposed on the removal of the 
infiltrated bone, and, as its nutrition is cut off from the side of the bone, it 

1 Vide Lancet, March 1883 ; also Children s Hospital Abstracts, 1882. Since then we 
have seen two or three similar cases. 



656 Diseases of the Bones 

usually gives way, and in such cases the joint becomes involved. We have, 
however, seen a case where complete recover)' with a movable joint occurred 
although the articular cartilage was thus exposed. 

Case. Osteomyelitis of Tibia. — Annie L. , age 3 years ; admitted November 4, 1884. 
History good. In June 1884 fell downstairs; in August first complained of pain in 
left leg ; it then began to swell, and has been slowly increasing ever since— rapidly during 
the last fortnight ; health failing ; has pain at night, &c. On admission, tense swelling of 
nearly the whole tibia and the soft parts over it ; skin shining, but not red ; temperature 
98 - 6°. Three incisions were made over the front and outer side down to the bone, but no 
pus escaped. She was relieved, pain disappeared, and swelling subsided. She was dis- 
charged on November 18. Readmitted December 16, 1884. The left tibia is enlarged in 
nearly its whole length, and is very tender on palpation over its lower third. Some pro- 
minence of superficial veins just above the ankle, but no discoloration of skin and no 
fluctuation ; temperature normal. January 8, under spray, incision made over tibia just 
above the ankle ; periosteum found much thickened ; a small gouge was easily pushed into 
the centre of the bone, and some pus welled up ; a quantity of soft disintegrating bone, 
infiltrated with pus, was gouged away until a fairly healthy surface was reached ; drainage 
tube inserted ; iodoform and wood-wool dressing. On January 19 tube removed ; and on 
February 2 wound almost healed, but leg not diminished in size, and presents same 
general characters as on admission. Readmitted March 30, 1885. The wound from last 
operation has not healed, and is still discharging ; swelling has spread up the tibia as far 
as knee-joint ; considerable thickening. April 30, no change in condition ; temperature 
occasionally ioo° at night. Esmarch's bandage applied, and incision afterwards made, 
about 2.\ inches long, over lower third of tibia ; periosteum detached and a new casing of 
bone, about \ inch thick, exposed ; on cutting through this with a chisel, softened bone 
infiltrated with pus was removed, and at lower end a sequestrum about 2 inches long was 
extracted. A second incision was afterwards made over upper third of tibia, and the bone 
found in similar diseased condition ; the whole of the interior of the tibia was gouged and 
scraped out, so that a probe could be passed from the upper to the lower opening ; iodo- 
form and wood-wool dressings and back splint applied. May 26, lower wound healing ; 
still large cavity at upper; much discharge ; temperature hectic, 96 - 4°-ioo - 4° ; takes food 
well. June 9, wounds slowly filling up ; suppurating glands at angle of jaw opened ; 
temperature 98°-io2°. June 29, wounds superficial, but still much discharge. July 20, 
lower wound almost healed ; upper filling up and contracting ; less discharge ; tempera- 
ture normal. August n, still slight discharge from both wounds ; sent home on back 
splint. Readmitted October 24. Leg more swollen than when last in hospital ; still two 
sinuses over left tibia. The limb was finally amputated, as the joint became involved. 

The other forms of diffuse inflammation which may attack the marrow 
of bones have been already mentioned : in the rarefying form the medulla may 
be replaced by deep red or maroon-coloured granulation tissue, and the 
bone may become so soft as to readily break down under the finger ; such 
condition may, however, be recovered from. We have known a case where 
the femur was so affected, and recovery took place without any unusual 
difficulty. 

In sclerosing or condensing osteomyelitis the medullary cavity may be 
almost entirely filled up with irregular dense masses of bone, and sometimes 
isolated central sequestra exist under such circumstances. 1 

Scattered miliary tubercles may sometimes be found in the medulla of 
bone as a part of a general tuberculosis ; they are, however, only found post 
mortem, as they give rise to no symptoms during life. 

1 A combination of these two conditions appears to have existed in a case recorded by 
Mr. Paul in the Med. Press and Circ. 1884. 



Strumous Dactylitis 657 

The pynemic variety of osteomyelitis is occasionally met with. In one of the most 
characteristic cases that we have seen, a boy eleven years old, who was in the habit of 
getting wet and drying his clothes on him, complained of pain in the feet ; the right foot 
and subsequently the knee swelled, the latter suppurated and discharged profusely a fort- 
night later ; the left elbow, the right hip, and the left knee then were attacked. On 
admission, ten weeks after the onset of the illness, both hips, both knees, and the right 
ankle, the left elbow, and the left shoulder, were swollen ; there were bedsores, and he 
had a systolic murmur and some evidence of pneumonia ; the urine was albuminous ; he 
was much wasted, and his skin was diy and harsh. A month after admission the left 
elbow was incised ; at that time there was brawny thickening over the upper part of the 
same arm ; ten days later, on exploring the humerus, there was found to be extensive but 
ill-defined mischief in it ; a fortnight after, the disease had extended so that the whole 
humerus was the seat of osteomyelitis ; pus discharged freely from the medulla at the 
upper part of the bone. The limb was amputated at the shoulder joint ; in doing so a 
large axillary abscess was opened. The shoulder joint was healthy, the elbow disorganised ; 
there was a sequestrum at the surgical neck of the humerus. He recovered fairly well 
from the operation, but subsequently fresh mischief occurred in the thigh, and he was 
removed by his friends, probably to die. 

Treatment of Chronic Osteomyelitis. — The treatment of the different 
forms of chronic osteomyelitis has been almost sufficiently indicated in the 
description of the disease. The general management will be that of 
tuberculous children : locally, in the early stages, rest to the part by means 
of splints, and in some cases confinement to bed, is all that can be done. If 
the disease does not subside, the bone must be freely exposed — the limb 
having been made bloodless by the elastic bandage, and the bone gouged 
away, all tissue that is dead or infiltrated with pus being removed ; if the 
mischief spreads far along the medulla, a groove must be cut in the bone, 
and all affected cancellous tissue scraped away. Should no repair take place 
and the disease spread to an adjacent joint, if the child's health is good, an 
attempt may yet be made to save the limb by incising the joint and draining 
it ; in some cases, however, nothing seems to arrest the disease, and ampu- 
tation is required. 

Washing out cavities with carbolic or mercurial lotion (1 in 4,000), and 
free dusting with iodoform, is perhaps the best wound treatment. In some 
cases it is a good plan to try the application of the actual cautery to the 
interior of the bone, in the hope of arresting the tuberculous process. In 
pyaemic cases incision of abscesses, removal of sequestra, and amputation 
are the only local resources, and each case has to be judged on its own 
requirements. 

* Strumous Dactylitis.' — The condition sometimes called ' strumous 
dactylitis ' requires brief mention here. The disease is simply chronic tuber- 
culous osteomyelitis, or more rarely periostitis, attacking usually the first 
phalanx of one or more fingers ; sometimes the metacarpal or metatarsal 
bones are affected. The disease usually begins as a hard, painless swelling 
of that segment of the finger, though occasionally there is a good deal of pain, 
and always some tenderness. If no treatment is employed, the swelling 
increases, the soft parts become involved, abscesses 1 appear usually at the 

1 It must be understood that here as elsewhere the words ' abscess ' and ' pus ' are, in 
relation to tuberculous lesions, used in a sense implying the naked-eye appearance rather 
than the actual pathological condition. The ' pus ' is broken-down caseous tuberculous 

U U 



6q8 



Diseases of the Hones 



sides of the finger, and on their bursting or being opened thick curdy pus, 
with, perhaps, some bony detritus, escapes. On further examination, a large 
cavity is found occupying the site of the old shaft, which is either entirely 
gone or remains in part as a cheesy sequestrum, or in some cases, if the 
abscess is opened early, appears to be simply bare. Around the cavity, 






Fig. 142.— Multiple ' Tuberculous 

Dactylitis.' 



Fig. 143. — Shows overgrowth of one Thumb, 
which had been long'the seat of Tuberculous 
disease. This is a rare condition, and should 
be compared with fig. 139 of overgrowth of 
the tibia. 



which is filled with pus and caseous matter, is a thin layer of new bone 
formed by the periosteum. As successive layers of new bone have been 
laid down and absorbed, so-called ' expansion ' of the bone has occurred. 
After removal of all the cheesy matter and sequestra the finger may 
gradually shrink and get well, but is shortened, distorted, and usually weak 





i 



Fig. 144. — The hands of an adult showing the effects of Tuberculous Dactylitis in childhood. 



and useless. Sometimes the destruction is so great that amputation is 
required. When seen in the earlier stages, constitutional treatment, with 
fixation of the finger on a splint and gentle pressure, will sometimes succeed 

material diluted with serum, and mixed with simple inflammatory products, and not the 
true pus of an acute abscess. — Vide Watson Cheyne's Lectures, i?r//. Med. Jour. 1890, 
for a good description of the process. 



Sypliilitic Dactylitis — Leontiasis Ossea 659 

in arresting the disease. It has been recommended to excise the bone sub- 
periosteally in the early stage, and this would no doubt cut short the disease, 
but the finger is not likely to be of much use. It is better treatment to wait 
patiently, and keeping the finger quietly fixed on a splint to try the effects 
of pressure and general hygiene ; when sequestra are present they must, 
of course, be removed, and should no progress be made the cavity must be 
cleared out — but, as a rule, a more useful finger is obtained by expectant 
than by active treatment. 

Should, however, abscess form, the best plan is to freely open and 
carefully scrape out the abscess cavity, removing all caseous material. The 
cavity should then be well dusted with iodoform and boric acid or some 
iodoform emulsion injected, and the wound should be closed by sutures 
without drainage. Primary union will usually be obtained if the wound is 
kept aseptic. 

Often many fingers are affected, and the disease is most commonly a 
part of ' General Surgical Tuberculosis ; ' it is most frequently met with in 
the first few years of life. The disease is probably sometimes periosteal 
rather than endosteal. 

' Syphilitic Dactylitis,' so called, is more often described than met with. 
The general appearance closely resembles that of ' strumous dactylitis,' and 
it is said that in children the disease is usually primarily an osteomyelitis, 
though the gummatous material may be deposited first either in the peri- 
osteum or soft tissues overlying it. The occurrence of ' dactylitis ' in a child 
showing other signs of congenital syphilis would lead to a suspicion that the 
affection of the fingers was also specific. The results are usually very much 
the same as those of the tuberculous lesion, and the treatment is simply that 
of syphilis. 1 

' leontiasis Ossea ' is a disease in which the bones of the face, especially 
the upper and lower jaws and'the malar bones, undergo hypertrophy. The 
disease begins in early life and may go on indefinitely. In a case we saw 
which had been under the care of Dr. Brown, of Bacup, and Mr. T. Jones, 
the disease began at 9 years old, and the patient when we saw him was 28. 

We have under our care now, 1899, a boy in whom the disease began as 
a slowly increasing thickening of the ascending ramus of the lower jaw ; the 
temporal bone, maxilla, and malar are now affected, and the nasal process 
of the opposite maxilla is beginning to enlarge. No medicinal treatment 
has had any effect. 

1 Vide Eschle in Langenbeck's Archiv, xxxvi. 1887; or an abstract in Med. Chron. 
February 1888. 



66o Diseases of the Joints 



CHAPTER XXX 

DISEASES OF THE JOINTS 

Diseases of the Joints. — There is no essential difference between the 
joint diseases of children and those of adults, but certain forms of disease 
are found most typically, or even almost entirely, in childhood. The con- 
ditions of growth as regards the relations of epiphyses to the adjacent joints 
and to the shaft of the bone are, however, most important factors in deter- 
mining the occurrence of disease and the kind of lesion met with, and, 
further, the liability of children to the various exanthemata is of much 
importance in regard to joint affections. Ordinary acute synovitis from 
injury or cold is in no way peculiar to, nor even specially common in, 
children, and need not be discussed here ; while hip disease, acute sup- 
purative arthritis of infants, scarlatinal synovitis, and even the common 
tuberculous pulpy disease, are instances of the modifying effects of the condi- 
tions of childhood upon forms of lesion which are also to be met with in adults. 

In early life the lesions of joints are more complex than in adults, for 
the reason already alluded to, that not only may disease begin in the joint 
structures proper, but it may often reach the articulation by extension from 
the neighbouring epiphysis or epiphysial line. It is generally said that bone 
lesions are limited by the epiphysial zone and do not extend to the bone 
below ; this, as already shown, is only partially true, and, besides this, disease 
spreads frequently from a starting point in the epiphysial line, or from the 
periosteum of the diaphysis, and extends to the capsule, and so to the synovial 
membrane. There is, however, often effusion into a joint adjacent to bone 
disease without actual continuity of disease. (For furthur details see chapter 
on Bone Diseases.) 

Joint disease, then, in children may arise as a simple acute serous 
synovitis, which may subside, suppurate, or become chronic. Chronic 
simple serous synovitis is, however, rare in children. There may be 
a primary acute or chronic tuberculous synovitis. Pyaemia or certain of the 
exanthems, notably scarlatina and typhoid, may give rise to an acute, some- 
times suppurative, synovitis, while measles and whooping cough, as well as 
scarlet fever and typhoid, may result in a development of tuberculous lesions. 
Finally, the joint disease may arise by extension from the shaft, epiphysial 
line, or from the epiphysis itself, and possibly from the ligaments and 
tendon sheaths in exceptional cases. The specific fevers are not so often, 
as is sometimes stated, the direct cause of joint disease : it is in most cases 



Patlwlogy of Joint Diseases 66 1 

rather that the depressing effect of the fevers makes the child more liable to 
the onset of disease — thus of 125 cases of joint disease, taken consecutively 
from our records, including cases of disease of the hip, knee, shoulder, 
elbow, ankle and tarsus, and wrist joints, in only six cases was the joint 
affection a sequela of measles, in four of scarlet fever, in two of typhoid, and 
in three of whooping cough. Only those cases were reckoned in which there 
was no interval of health between the exanthem and the joint trouble. 

In certain joints bone lesions are far most commonly primary, as in the 
hip, and perhaps the shoulder ; in other joints, as in the knee, ankle, and 
wrist, bone disease when present is much more often secondary to a primary 
synovial inflammation, while in other joints again, as in the elbow, either 
starting point is common. 

The hip is by far the most frequently diseased joint in children, and the 
knee comes next. Of 698 cases of joint disease under our care in the out- 
patient department of the Children's Hospital in three years, 369 were cases 
of hip disease, 160 of knee disease, and all the other joints together amounted 
to 169. Disease of the spine is excluded from this calculation. 

For any detailed account of the pathology and symptoms of each diseased 
joint we must refer to the special works of Barwell, Macnamara, Howard 
Marsh, Hueter, and others ; space will only allow of selection of the hip and 
knee as types of the two forms of joint disease found in childhood, with a 
brief reference to the other most commonly affected articulations. Hip 
disease stands so much by itself that its consideration will be most con- 
veniently postponed till after that of the other joints. 

Chronic disease of the knee joint may be taken as the type of joint 
disease beginning in synovial membrane— pulpy disease, chronic synovitis, 
tuberculous synovitis, white swelling, and various other titles, all implying the 
same condition. 

Here we may say at once that we believe all the cases of chronic dis- 
ease of joints marked by great thickening of synovial membrane, with little 
or no tendency to accumulation of fluid, but with great tendency to the 
formation of small multiple ' abscesses ' in the thickness of the gelatinous 
tissue, are truly tuberculous in the most strict sense. In some cases a consider- 
able amount of fluid, either serous with caseous material and flakes of lymph, 
or more puriform, is found in the joint ; this is, however, not a common con- 
dition in children. In many instances evidence of tubercle elsewhere and a 
tuberculous family history will be found ; x in many, death ultimately results 
from tuberculosis of other organs. The anatomical characters of tubercle 
are constantly to be found in the pulpy tissue, and, though not so constantly 
or readily, yet in a large number of instances tubercle bacilli have been 
detected. 

The usual history of a case of chronic tuberculous synovitis of the knee 
joint in a child is as follows. There is perhaps a history of phthisis or joint 
disease in the family ; the child has been healthy, till at the age of, say, four 
years it was attacked by measles or some other exanthem. It was slow in 

1 In 192 histories of chronic joint disease under our care (the spine being included), in 
43 ( + 6 doubtful cases) there was a tuberculous family history ; in 61 ( -f- i doubtful case) the 
disease had followed an injury. In 19 cases out of 11 1 patients there was more than one 
lesion, i.e. there was evidence of tubercle elsewhere. 



662 Diseases of the Joints 

recovery, and was never quite strong afterwards ; a year later, perhaps, it 
received some injury to the knee. Shortly after the knee swelled, but gave 
rise to no great pain or inconvenience, except a slight limping and feeling 
of tiredness ; the swelling slowly increased and became somewhat more pain- 
ful, especially at night, with night startings. We cannot too strongly insist 
upon the fact that tuberculous disease of joints may go on for months, steadily 
getting worse, without any pain at all, and with but little impairment of 
mobility ; this so frequently occurs, and yet is so frequently a cause of mis- 
takes, that we desire to emphasize the statement here. At this time the child 
we will suppose comes under observation. The knee is found markedly 
larger in circumference than its fellow, its natural hollows are obliterated, it 
may or may not be slightly hotter than the other, there is slight flexion, and 
usually it cannot be fully extended, any attempt to do so causing pain. 
There is considerable pain on pressure over the inner tuberosity of the tibia, 
and to a less degree over the outer side. The swelling is soft, elastic, and 
pseudo-fluctuating : it may exactly follow the normal outlines of the joint, or 
be more globular, the upper synovial pouch not being thickened ; occasion- 
ally the swelling is almost limited to the upper sac. There is pretty free 
mobility of the joint at this stage, unless an attack of acute inflammation has 
supervened upon the chronic mischief. Such a case left to itself will later on 
become more flexed and less mobile, abscesses will form and burst at the 
sides or front of the joint, the swelling will increase, and the veins over the 
surface may become dilated and full ; the tibia will become subluxated back- 
wards and outwards, and at the same time rotated outwards upon the femur ; 
the limb will become wasted and powerless. In many cases pain increases 
and the child's health suffers, until at last the pain and discharge, or the 
invasion of other organs by tubercle, w r ears him out. 

The severity of the symptoms varies greatly : in some instances pain and 
stiffness exist throughout ; in others free, though not usually full, mobility 
and absence of pain may be found during nearly the whole course of the 
disease. 

If a knee joint, such as the one described, is laid open, the synovial 
membrane is found everywhere converted into a thick, pinkish-grey or 
yellowish, semi-transparent material, soft and gelatinous to the touch, but in 
parts tough and elastic ; in parts the grey tissue is streaked with opaque 
fibrous bands, and here and there caseous foci will be found softening and 
breaking down — these are especially common towards the posterior part of 
each femoral condyle. These breaMng-down foci do not usually commu- 
nunicate with the cavity of the joint itself, which is largely filled up by the 
thick granulation masses, and contains little or no fluid. 

The pulpy tissue grows over the cartilages at first in delicate vascular 
tendrils or films, but afterwards these become thicker and form fleshy pads 
replacing the cartilage at the edge and lying in pits dug out of its surface, 
so that finally only a small central island of healthy cartilage remains in the 
middle of each condyle and each articular surface of the tibia. 

Often granulation sprouts spread beneath the cartilage and, detaching- 
it from the bone, give rise to superficial rarefying ostitis, ' subchondral caries,' 
which causes necrosis and separation of the articular cartilages. 

The semilunar cartilages are as it were embedded in the gelatinous tissue, 



Disease of the Knee 663 

and in some far advanced cases can hardly be distinguished ; usually, 
however, they are readily made out. The crucial ligaments are coated over 
with the pulpy tissue, and are often very vascular, with bright streaks of vessels 
running along them ; on scraping away this tissue the ligaments are found to 
have nearly their natural appearance, except that here and there a little 
sprout has forced its way between their fasciculi. The degree of destruction, 
however, of course varies in different cases, and in some the tuberculous focus 
is, at first, strictly limited to one patch of synovial membrane. 

The cavity of the joint is often subdivided into loculi by adhesions be- 
tween masses of the granulation tissue. On gouging out one of the granula- 
tion pits in the cartilage, it will be found in some cases not to extend through, 
in others the bone beneath is reached and locally eroded. 

The capsule and lateral ligaments, &c. are much thickened, and this 
gives rise to the deceptive sensation of bony thickening so often met with in 
the knee. However much it may appear that there is enlargement of the 
bones in a case of chronic disease of the knee, it is almost perfectly safe to 
say that the thickening is in the soft parts alone, and that there is no new 
bone formation. It is only very rarely that a layer of periosteal new bone is 
found beyond the limits of the capsule. The presence of new bone about a 
chronic tuberculous joint is usually a sign of repair and of subsidence of 
the disease ; sometimes, however, it is associated with central bone disease 
(chronic osteomyelitis), never, we think, with progressive synovial disease 
alone. Mr. Watson Cheyne, how r ever, states that microscopically thickening 
of bone trabecular precedes tuberculous infiltration in caries of the articular 
ends of bones. 

There is usually more or less atrophy of the bone adjacent to a chronically 
diseased joint. The cancellous tissue is more open in texture, and the com- 
pact tissue thinner than in health. Wasting of the bones, in fact, takes place, 
just as of the muscles and other tissues around the joint. These changes are 
general. When local patches of marked rarefaction are present, that part 
must be considered the seat of actual disease. 

In the great majority, however, of cases of disease of the knee the bone 
is healthy, unless the disease is far advanced ; when this is so, islets of soft 
rarefying bone and carious patches will be found, the latter in their early 
stages being recognised by the yellow 7 and red mottling in the neighbourhood 
of the articular cartilage, with some rarefaction. It is often very difficult to 
be certain of the condition of bone in very early stages of disease : patches 
of various shades of yellow and red are met with in perfectly healthy bone ; 
where there is any local rarefaction or opaque yellow deposit disease is 
present. In some instances, however, sequestra of varying size are found — 
most commonly in the femur, less often in the tibia ; usually the necrosis is 
at the back of one or other condyle ; we have, however, found it in the 
middle of the intercondyloid notch. When necrosis does occur the disease 
often tunnels a considerable way through the bone, or rather the disease has 
probably begun in the epiphysial line or epiphysis itself, and extended towards 
the joint. 

As Mr. Howard Marsh has pointed out, a condition of ' quiet strumous 
disease ' may exist, leading to a stiff joint without any active stage or suppu- 
ration ; we have seen such joints occasionally, and they are to be distinguished 



664 Diseases of the Joints 

by having a greater amount of solid thickening than occurs in serous syno- 
vitis, but less than in the ordinary tuberculous joint. 

Tuberculous Disease of the Shoulder is rare in children ; there is hardly 
sufficient evidence to show how often the disease begins in the synovial 
membrane and how often in bone. The swelling forms a globular mass, 
most prominent in front, and stiffness of the joint is usually marked. When 
suppuration occurs the abscesses usually point behind or in front of the del- 
toid, occasionally in the posterior triangle ; no information as to the primary 
lesion can be obtained from the position of the sinuses, since extra-articular 
abscesses due to epiphysitis discharge in the same spots. Disease in the 
epiphysial line may or may not lead to destruction of the joint. In one 
interesting case we removed, as a sequestrum, part of the upper end of the 
diaphysis, including the epiphysial line, and subsequently nearly the whole 
shaft of the humerus ; the inflammation had spread from the periosteum 
to the capsule, and the ligaments became so relaxed that there was a deep 
groove below the acromion, the humerus having dropped away from the 
scapula; the joint did not suppurate, and all went on well (fig. 141). 

We have only two or three times found it necessary to excise the shoulder 
joint in children ; in all the other cases the disease has subsided, or the case 
has been lost sight of. In one instance, where there was much necrosis, a 
very useful limb resulted with f-inch shortening, and but little wasting, but 
the joint was hardly at all mobile. 

Case. — Disease of Shoulder Joint. Excision. — Lewis H., age 4 years; admitted 
July 19, 1882. Three years ago the left arm was seen to be stiff and painful ; abscesses 
formed about the shoulder and were opened ; no bone removed ; for last eighteen months 
had been discharging a little constantly, and lately the child had lost flesh ; no phthisis in 
family ; other children healthy. On admission, rather pale, but fairly nourished boy ; 
general thickening all round the left shoulder ; a patch of red thinned integument, with 
pus beneath, in front of the insertion of the deltoid, and a sinus at the posterior border 
of the muscle : the pectoral fold bulged downwards and forwards ; there was pain in 
movement. July 26, much discharge, especially on pressure about the axilla ; very little 
mobility, even under chloroform, slight power of rotation alone remaining. August 2, 
the upper end of the humerus was excised, together with about an inch of the shaft, by a 
single straight incision at the anterior border of the deltoid ; two loose sequestra were 
found in an abscess cavity surrounding the head of the humerus ; the joint was entirely 
destroyed ; the glenoid cavity and acromion were roughened ; there was some deposit of 
new bone around the upper part of the shaft of the humerus ; the part removed was not 
entirely necrosed, but there was a large cavity in it ; terebene dressings, hand slung up 
to chest ; some rise of temperature followed. He went on well, but slowly; at one time 
;ome bare white bone was seen, but this vascularised subsequently, except a small part 
removed on August 26, and two more small pieces which came away in September. 
Passive movement was begun on September 23, and on the 28th more free movement was 
made under chloroform. He had chicken-pox in October, and was discharged with sinuses 
still open on November 8. Passive movement failed subsequently to give him any great 
amount of mobility. February 1883, he is well and strong, and has good use of the arm, 
but the movement is almost entirely of the scapula ; the limb is not much wasted, and 
there is f -inch shortening. 

Disease of the Elbow Joint arises either as a primary synovitis or about 
equally often as disease of bone ; in the latter case the olecranon or one 
of the condyles, most often the outer, is first attacked. Well-marked cheesy 
masses are often found in one or other condyle, but any extensive disease of 



Disease of the Elbow Joint 66$ 

the radius is very rare. Swelling extends all round the joint, but usually 
appears first over the radio-humeral line at the back of the joint. Later the 
front of the joint becomes swollen ; this is sometimes due to glandular en- 
largement, comparable to the swelling of the inguinal and iliac glands in hip 
disease ; in other cases the supra-condyloid gland suppurates. When the 
olecranon is the seat of the primary lesion the sinus is usually over it and 
leads directly, or nearly so, down upon it. 

In old neglected cases, the number of sinuses is sometimes considerable, 
and the soft parts are undermined and much destroyed by pulpy infiltration. 
The joint is kept slightly flexed, and there is usually much muscular wast- 
ing. Occasionally we think the disease begins in the olecranon bursa, which 
is so common a starting-point for mischief in older patients ; this bursa is 
sometimes chronically enlarged in children. Stiffness is an early and marked 
feature of disease of this complex joint, though the mobility of the fingers 
is good, even if there is much infiltration of the muscular attachments about 
the elbow. 

Case. — Joseph L. D. , age 3 years 11 months; admitted January 27, 1882. Left 
elbow - injured by a fall in April 1881 ; had been swollen ever since. On admission, 
healthy-looking child ; the left elbow was flexed and the hand semi-pronated ; very little 
mobility ; two sinuses at the upper and back part of the joint led down to rough bone ; a 
little tenderness, but no pain ; general swelling all round the joint. February 2, the joint 
was excised ; disease primarily synovial ; cartilage diseased, especially on head of radius ; 
operation not antiseptic ; the limb was put upon an angular splint. On the 13th passive 
motion was begun. On March 1 passive movement could be carried through the full range 
in all directions, and there was a little power of active movement ; the wound was nearly 
healed ; discharged. October 3, 1882, at out-patients' ; elbow quite healed ; had almost 
perfect range of mobility in every way, and the arm was strong ; he could lift a chair 
with it. 

Tne Wrist Joint is perhaps even more rarely affected with tuberculosis 
than the shoulder, but in children we have on three or four occasions had to 
excise the joint ; in all, the wrist joint itself, as well as the whole carpus, was 
disorganised, the disease having spread among the synovial sacs. In one 
instance the mischief began in the base of the second metacarpal bone, in 
the others the starting-point was apparently synovial. In two of the cases 
an excellent result followed, the whole of the carpus, the bases of the 
metacarpal bones, and the lower ends of the radius and ulna having been 
removed by a single median dorsal incision between the tendons of the 
extensor indicis and the extensor secundi internodii pollicis ; no tendon was 
cut through, though necessarily those attached to the parts removed were 
stripped back. In both of these cases a nearly perfectly mobile joint was 
obtained with almost full mobility at the metacarpo-phalangeal articulation 
— the point of greatest difficulty in disease of the wrist. 

Case. — Disease of Wrist Joint. — Annie E. , age 6 years. Admitted March 25, 1885. 
History unimportant. No cause known for swelling of left wrist, which began six months 
before admission ; much pain ; poulticed for three months. On admission, a strumous- 
looking child ; on palmar aspect of left radius at lower end is a sinus ; much thickening 
round wrist ; fluctuation in front of carpus ; movements of fingers perfect ; those at carpal 
joints absent. April 16, whole carpus except pisiform bone removed by longitudinal inci- 
sion on dorsum ; some bones broken down and unrecognisable ; cavity scraped, and drained 
through palmar sinus. May 1, wound has progressed fairly and is now healing. 15th, 



666 



Diseases of the Joints 
in wound ; arm on splint; result very gpod ; a itrong and mobil< 



^m 



/ 



.sent home ; tube stil 
hand (fig. 145). 

One patient remains sound ; the other, after keeping well for a long time, 
developed tuberculous teno-synovitis, which will probably cause some loss of 
movement. In the third case the carpus alone was taken away, with an 
even better result. The operation mentioned is practically Langenbeck's ; 
it is much simpler than Lister's method, and we think much superior to it : 
the bones which are not already softened and destroyed shell out easily 

from the pulpy material in which 
they are embedded. The position 
of the sinuses in carpal disease is 
inconstant, but the general appear- 
ance is shown in fig. 145. 

Chronic Tuberculous Disease 
of the Ankle is much less frequent 
than that of the knee ; but in four 
years we had 43 cases of disease of 
the ankle or tarsus admitted as in- 
patients at the Children's Hospital. 
Of these, excluding disease of the 
os calcis, most of the cases were 
probably primarily synovial, but in 
the tarsus extension of disease 
around the small bones so interferes 
with their nutrition, and so readily 
spreads to their interior, that in late 
cases there is always more or less 
destruction of bone. We can only 
recollect one, or perhaps two instances of primary necrosis of the astragalus 
setting up disease of the ankle joint ; but it is much more common to find 
mischief spreading from the lower epiphysis of the tibia to the joint. 

Except the posterior calcaneo-astragaloid joint, the anterior calcaneo- 
astragaloid and its continuation the astragalo-scaphoid joints are, perhaps, 
the most commonly affected of the tarsal articulations ; but the common sac 
or any of the tarsal joints may be attacked by disease, which then spreads 
from one joint to another. Calcaneo-astragaloid disease is very frequently 
the result of necrosis of the os calcis, and it not rarely extends upwards to 
the ankle joint itself. 

Disease of the ankle joint is marked by swelling at the back of the joint, 
obliterating the hollows on each side of the tendo Achillis, and then spread- 
ing round and below each malleolus, especially the inner (fig. 146) ; the 
front of the joint also becomes swollen, and acquires a peculiar flatness or 
squareness of outline as a result of loss of salience of the extensor tendons. 
The foot is usually kept with the toes pointed, at other times it is dorsi- 
flexed ; the leg rapidly wastes ; later, sinuses appear, usually above or behind 
the malleoli. It must be remembered that disease often extends from the 
joint into the sheaths of the neighbouring tendons, and in such cases suppu- 
ration or swelling may track up the leg or along the foot for a considerable 
distance ; the general conditions do not differ from those met with in the 





Tuberculous Disease of the Wrist. 



Chronic Tuberculous Disease of the Ankle 



667 



knee. In disease of the tarsal joints the foot is swollen in the position cor- 
responding to the affected articulation, and movement of the particular joints 
may be painful. This is not, however, a very trustworthy symptom in tuber- 
culous disease, though of much value in acute inflammation.. When the 
common sac is involved the foot assumes a bulbous look, with the toes pointed 
and pressed closely against one another. The disease often spreads beneath 
the extensor or along the plantar tendons, and gives rise to widespread 
mischief in the soft parts, so that a 
sinus by no means always indicates 
disease of the nearest joint. The arch 
of the foot is seldom lost, in consequence 
of the resistance of the rigid structures in 
the sole of the foot. With two exceptions, 
the disease is usually primarily synovial : 
one is that already mentioned of caries 
or necrosis of the os calcis, which often 
extends to the calcaneo-astragaloid joints ; 
and the other, that it is common for dis- 
ease of the first metatarsal bone to extend 
backwards to the joint between it and the 
internal cuneiform. 

It is sometimes difficult to be sure 
whether an abscess on the dorsum of 
the foot — the most common situation for 
pointing in tarsal disease — is connected 
with the joints or is merely peri-articular : 
in some cases pain on pressure or move- 
ment of individual joints, localised by 
pressing back towards the ankle individual 
toes in turn, in others swelling over some particular joint or in the sole, 
will indicate a deep lesion ; but often exploration is required before a certain 
conclusion can be arrived at. 

Acute simple Serous or Suppurative Synovitis is uncommon in child- 
hood except as the result of injury or rheumatism ; any joint may be affected, 
and the symptoms in no way differ from those seen in adults. There is 
swelling, which, being due to distension of the synovial sac, follows its out- 
lines ; heat and pain, with immobility and some constitutional disturbance, 
are also present. The inflammation commonly subsides readily by treat- 
ment with splints and ice or evaporating lotions, and leaves no ill results. 
In some cases, however, usually in unhealthy children, or where there has 
been a wound of the joint, suppuration occurs ; all the symptoms are then 
greatly aggravated, any movement is exceedingly painful, and the tempera- 
ture may rise to io3°-io4°. 

The acuteness and severity of the symptoms vary much in these cases : 
in one instance the hip joint suppurated, nearly the whole thigh was occu- 
pied by a large abscess, the head of the femur was partially destroyed, 
and the mischief extended to the knee joint, which also suppurated ; both 
joints were incised, but the child sank and died. Pus was found in the knee, 
with superficial erosion of cartilages ; the synovial membrane was thick and 




146. — Tuberculous Disease of the 
Ankle Joint. 



668 Diseases of the Joints 

hyperaemic, the thigh was infiltrated with sero-purulent fluid, and the 
acetabulum was granulation-lined. 

In other cases there is a thick ' mucous ' discharge and the cartilages are 
not destroyed : in these cases incision generally results in recovery with a 
mobile joint. This form of disease most commonly occurs in children under 
two years of age, and is met with in the knee — less often in the shoulder, 
elbow, hip, or foot. Somewhat like the above-mentioned catarrhal inflam- 
mation of joints, described by Volkmann, appears to be a form of painless 
purulent exudation, not connected with pyaemia or epiphysitis, which has 
been described by Atkin, of Sheffield. 1 

Pyaemic Joint Disease is not rare in children, and may run an acute or 
chronic course. The articular lesions may be the only evidence of pyaemia, 
or they may occur in conjunction with bone or visceral abscesses. Both 
forms of disease are exceedingly dangerous, though neither by any means 
always fatal. We have had a case under our care of a boy aged 3^ years, 
who had pneumonia after measles, and subsequently suppuration in one 
shoulder and one knee, with effusion into one of his ankles, and double em- 
pyema, together with abscesses in other parts ; this child recovered perfectly, 
with a mobile knee, though with a somewhat stiff shoulder. Effusion into a 
joint in pyaemia is not always purulent, nor does the presence of pus in a 
joint or elsewhere always demand incision and drainage ; the effusion may 
be absorbed, or, after aspiration, may not recur, and on examination the 
articular cartilage may be found quite smooth and healthy, or only somewhat 
yellow and opaque. In other cases, however, the cartilage becomes necrotic, 
or it may rapidly melt away entirely or in patches, leaving the articular 
lamina of bone smooth and bare ; this is perhaps the most typical condition 
of acute pyaemia. 

Exanthematous Synovitis, or that form of joint disease which occurs 
in connection with the specific fevers, has already been alluded to in discuss- 
ing those affections, and scarlatinal synovitis or rheumatism has been fully 
described (p. 256). A second variety occurs generally, but not always, later 
in the course of the fever, and usually in connection with severe throat lesions. 
The affected joint suppurates and becomes disorganised ; this is clearly a 
pyaemic condition. It must also be remembered that the exanthems are 
sometimes a determining cause of the appearance of a tubercular lesion. 
Typhoid synovitis is rare, and is said to be almost limited to the hip joint ; 
we have, however, seen the knee attacked, and, as Gibney has pointed out, 
the spine may be affected. Synovitis, probably pyaemic, occurs as a rare 
complication of diphtheria. An exanthem such as scarlet fever or measles, 
occurring in the course of a joint disease, usually gives rise to suppuration 
and rapid destruction of the joint ; in some cases, however, it appears that, 
as in the case of erysipelas, the more active inflammation does good by 
causing melting away or absorption of the chronic inflammatory material. 

' Pathological dislocation,' i.e. displacement of the articular extremity of 
a bone, as a result of softening of ligaments is sometimes met with in cases 
of exanthematous synovitis, and we have seen it more than once in post- 
typhoid inflammation of the hip joint. Both hips may be attacked at once. 

1 Brit. Med. Jour. July 11, 1885. 



Syphilitic Synovitis 



669 



Chronic Rheumatic Arthritis occurs occasionally in children, both in its 
polyarticular (nodular) and monarticular forms, as pointed out by Charcot 
and others, and we have once or twice seen it. It must be remembered 
that such cases may become tuberculous, and we have seen a joint which 
had the characters of chronic rheumatic arthritis well marked, which sub- 
sequently became an ordinary pulpy knee, just as occurs in adults ; the two 
conditions may be seen co-existing in one joint. 

Case. — Chronic Rheuitiatic Arthritis. — Mary Jane E. , age 13 years ; admitted Feb- 
ruary 25, 1884. No rheumatic or gouty history. Duration since August 1882, when she 
had pains in her shoulders, which subsided in a week. Nine months ago had pain in left 
hip, which lasted four months ; then the left knee was attacked ; both were swollen ; 
no other joint affected ; pains worse in wet weather ; not increased in bed ; sweats a good 
deal at nights ; urine often contains red lithates. On admission, well nourished; slight 
eczema of face ; heart sounds normal ; right knee a little swollen ; no crackling or thicken- 
ing ; no osteophytes. Left knee, thickened synovial fringes ; well-marked crackling; edges 
of both condyles distinctly lipped. Her condition improved with blistering and iodide of 
potassium, and she was sent out on March 15. 




Fig. 147.— Congenital Syphilitic Synovitis of both Wrists. 

Syphilitic Synovitis is occasionally met with ; we have, however, only 
seen a few cases of pure synovitis in the first few months of life in congeni- 
tally syphilitic children ; the most common condition is syphilitic telostitis. 
A subacute recurrent syphilitic synovitis occurring in older children is met 



6/0 Diseases of the Joints 

with ; it sometimes rapidly subsides under antisyphilitic treatment, as in the 
following- instance ; but this is not always the case— it is sometimes rather 
intractable. 

Cask. — Syphilitic Synovitis of Knee. — Jane B. , age 3 years 3 months ; admitted Octo- 
ber 31, 1882. A history of syphilis in the brothers and sisters, of whom there have been 
twelve, seven being dead ; patient herself had always been hearty ; two years ago the left 
knee swelled without known cause, but recovered completely in fourteen days ; th< 
had been bad since May 1882 ; the right eye was first affected, and the left was only 
attacked three weeks ago ; has not had much photophobia ; the left knee began to swell 
on October 29 ; she had a good deal of pain in it. On admission, the left knee was much 
distended with fluid, and was slightly hotter than the right ; she had well-marked inter- 
stitial keratitis, which was, however, subsiding; facial aspect and teeth also characteristic ; 
no other signs marked. Under hyd. c. cret. and pot. iod. , together with a back splint for 
the knee, all the swelling rapidly subsided, the eyes improved, and she was discharged, 
nearly well, on November 21. 

Clutton has noticed the occurrence of symmetrical synovitis of the knee in 
congenital syphilis, and Gutterbock l other cases of asymmetrical effusion ; 
we have seen the same thing associated with periostitis of both tibiae. Car- 
rington and Lane record a case of suppurative synovitis of the hip, knee, 
shoulder, and both elbows in a child with congenital syphilis ; there was 
rickets also present, but no epiphysitis. 2 

The best treatment of these cases is the administration of iodide of 
potassium in full doses, as children take it well, with hydrarg. c. creta, 
while mercury ointment should be rubbed into the part affected ; if there is 
much pain, blisters will sometimes give relief. Gonorrhoea! rheumatism 
is sometimes met with in children in association with vaginitis or ophthalmia 
neonatorum, as pointed out by Clement Lucas and others. We have seen 
an infant a few weeks old in which a stiff flexed wrist remained as the result 
of what was described as ' erysipelas of the hand.' The swelling of the 
hand was noticed on the evening of the day the child was born, and it had 
also purulent ophthalmia. 

Acute suppurative Arthritis of Infants, first described by Sir T. 
Smith, 3 is a remarkably well defined affection of fairly frequent occurrence. 
It is limited usually to children under a year old, though we have 
occasionally seen it in older children, the eldest being nearly two years of 
age. Pathologically the disease is an acute epiphysitis leading to rapid 
destruction of the ossifying centre of the bone it attacks, with perforation into 
and disorganisation of the adjacent joint. In one instance the epiphysial 
nucleus of the head of the femur was found lying loose in an abscess cavity, 
or rather in a sinus leading from the joint. A large number of the infants so 
attacked die of pyasmia. The hip is the joint most frequently affected, the 
knee standing next. Of ten cases of our own the hip was involved in eight 
instances — six times alone ; in one other case the knee was involved by direct 
extension, and in another the wrist, shoulder, and hip were implicated. In 
two instances the disease followed whooping cough, in one it came on after 
an injury, and in one some evidence of the onset of the disease in utero was 

1 Rev. Mens, des Mai. de I ' Enfance. 

2 Brit. Med. Jour. January 1885. Path. Soc. Trans. 1885. 

3 Morrant Baker, John Poland, and one of the present writers, as well as others, have 
also contributed to the literature of the subject. 



Acute Suppurative Arthritis 671 

obtained. We have adopted Sir T. Smith's view that the lesion is primarily 
epiphysial ; and it is so certainly in the majority of cases, but in one or two 
we have not found evidence of anything more than synovial disease ; these 
would perhaps rather correspond to Volkmann's ' catarrhal synovitis ;' and, 
on the other hand, we have met with several cases in which the abscess 
pointed outside the joint, the cavity of which was not involved. In one 
instance the lesions were secondary to a cervical abscess, and there was 
epiphysitis of one shoulder and a peri-articular abscess of the other, so that 
sometimes at least the presence of an abscess about a joint in an infant 
is not due to an epiphysitis, and sometimes it is not an arthritis. Battle 
believes it to be usually an affection of the end of the diaphysis 1 primarily. 
It is often difficult to make out the connection between the abscess and the 
joint, but with care it may be found in most cases. The severity of the 
disease varies considerably ; in some instances the mischief goes on for two 
or three months, in others it is fatal in a few days. The characteristic 
features are the age of the child ; the existence of great swelling round the 
affected joint, often involving nearly the whole limb, and not uncommonly 
' flying about ' — i.e. one limb becomes swollen and then subsides, then the 
swelling appears in one of the other limbs, and finally the disease becomes 
localised in one joint only, leaving the parts first attacked uninjured. This 
curious feature of the disease perhaps indicates its relation to pyaemia. In 
acute cases there is much fever, but there may be little rise in temperature 
in the more chronic ones. We have seen a case in which tubercle was 
apparently engrafted on a case of ' acute suppurative arthritis ' of the hip. 

The symptoms and course of the disease point to thrombosis, extending 
from the vascular cancellous tissue, or to embolism, but we have not verified 
this condition post mortem. The size of the abscesses is sometimes remark- 
able ; in one case the whole thigh, from the hip to the knee, was a bag of 
pus, both joints being involved. 

These children are generally much prostrated and often very anaemic, 
worn out by pain and rapid outpouring of pus. 

Treatment consists in early and free incision into the abscess, opening 
the joint if it is swollen, and keeping it well drained. Stimulants and abun- 
dant nourishment must be given. It is not necessary to put the limb in a 
splint in infants, but it is a good plan to tie it up in a pillow so as to keep it 
steady ; there is little or no fear of a stiff joint. Probably half the acute cases 
die. If recovery takes place, the limb is usually shorter and weaker than the 
other, but there may be a practically perfect recovery, and there is generally 
good mobility. We have several times seen older children with weak limbs 
clearly the result of this disease in infancy. Arrest of growth is less likely 
to occur where the hip is involved than the knee. The two following are 
fairly typical cases. 

Cask. — ' Acute Suppurative Arthritis' of Hip. — Alfred W. , age 9 months ; admitted 
May 3, 1884. History good ; never very strong ; no known cause ; swelling about hip 
one month ago. On admission, pale, but not thin ; abscess round right hip ; grating felt 
in joint. Incision, head of bone gone. 5th, takes food well ; much discharge ; temperature 
subnormal. Did moderately, but on 15th still looked pale and ill. Sent home on 24th 

1 Brit. Med. Jour. May 9, 1891. 



I 



672 Diseases of the Joints 

with* wound superficial. Subsequently fresh suppuration occurred, but after a hard 
struggle the Limb became sound and well, with good mobility and little shortening. 

Cask. — 'Acute Suppurative Arthritis' of Knee. — Mary H., age 9 months; ad- 
mitted March 21, 1885. Family history good; child first noticed to be feverish and 
restless nine days ago ; the knee then swelled rapidly, and was very tender ; the .swelling 
is now less than it was a few days ago. On admission, a well-nourished child ; right knee 
swollen, hot, tense, and shining ; fluctuation felt readily ; girth 10 in. as compared with 
yh in. on the left side ; temperature 97°. Joint freely incised on outer side, and a quantity of 
pus escaped. 23rd, swelling gone down ; a fair amount of discharge ; takes food well, and 
sleeps well ; temperature 101 . April 1, pus tracking upwards and inwards ; a larger tube 
inserted. 13th, swelling less ; doing well. May 2, all swelling gone ; tube removed, nth, 
wound healed ; all well. 

Acute Tuberculous Synovitis is not a very common affection ; it does, 
however, occur, and rapidly goes on to suppuration in quite young children. 
The most typical instance we have seen was in a baby ten months old, in 
whom suppuration of the ankle occurred a week or two after a scald over the 
joint. On incision a few drams of curdy pus escaped. A week later the 
child died of pneumonia and was found to have generalised tuberculosis ; 
the lungs, liver, kidneys, spleen, and brain were all affected. Here, from the 
condition of the tubercular masses in the brain, it was clear that tuberculosis 
existed at the time of the injury to the skin over the ankle, and the joint 
subsequently became tuberculous. The case serves to illustrate the fact that 
in the first year or two of life suppuration occurs as a result of inflammation 
more readily than in older children. Acute tuberculous disease also some- 
times follows strains or fractures in the neighbourhood of joints ; thus we 
have seen advanced pulpy disease of the elbow, in a girl of eight years, nine 
days after an injury which loosened the epiphysis of the inner condyle of the 
humerus. The following case is also noteworthy as an illustration of the 
occasionally acute onset of the disease ; 

Case. — Acute Pulpy Knee. — Harry A., age 3 years 9 months; admitted January 4, 
1885. No tuberculous history ; had measles at two years of age, followed by whooping 
cough ; disease of knee first noticed fourteen days ago ; no cause known. On admission, 
stout, well-nourished boy ; right knee is much enlarged, joint hollows obliterated ; swelling 
elastic, no distinct fluctuation ; movements very limited and painful; right kneeiof in., 
left knee 9 in. ; extension applied. 17th, knee straight ; no night pain ; general condition 
good. 21st, as some fluid was thought to be present, the knee was aspirated, and two 
drams of sero-pus drawn off. 25th, temperature normal ; general health good, but there 
is still fluid in the joint. February 4, the knee was enlarged to its original size, .a Thomas's 
splint was applied, and he was sent home. Readmitted April 29. He wore the splint up 
to readmission, and has been doing fairly well till lately. On admission, the swelling has 
increased to n in. and extends some distance up the thigh ; the veins are full, and the 
skin tense and shining ; the patella floats ; free incisions were made into the joint : a 
large quantity of turbid serum escaped from the incision on the outer side, while from 
the inner one, which was somewhat lower down, pus flowed ; operation antiseptic ; 
drainage as usual ; the wound was dressed on May 2 and 12, when there was not much 
discharge and the knee was quiet ; temperature never above 99 "4°. 26th, still a good deal 
of swelling ; some thick, cheesy pus squeezed out ; the knee did not improve much, and 
on June 29 he was taken home by his friends. July 6, readmitted, knee as on discharge. 
18th, temperature 102 ; some retention of pus on inner side of thigh above knee. 23rd, 
excision of joint ; much thick pulpy material, cartilage eroded, but surface of tibia healthy, 
except a small portion at the inner margin, which was gouged away ; surface of femur 
bare and rough, and bone soft and showed several points of pus ; when gouged the bone 
was quite soft, yellow and infiltrated with pus ; this was removed, leaving a cavity \ in. 



Treatment of Acute Tubercula?' Synovitis 673 

long and J in. deep in the inner condyle; the bone surface and the upper synovial cavity 
were cauterised with the thermo-cautery, dusted with iodoform, and the limb was put up 
in a Howse's splint ; wood-wool dressing ; on section of the part of the femur removed 
a yellow caseous mass was found surrounded by soft bone ; there was much shock for 
some hours, which was treated by opium, warmth, and alcohol ; did fairly well, and tem- 
perature was never above ioo° till 29th, when the knee was dressed for the first time, the 
temperature having run up suddenly to 104 (?) ; wound looked well and was quite sweet ; 
pads of wood-wool uniformly soaked ; temperature fell and was not above 101 after 
30th. August 3, free discharge, doing well, but splint soiled ; it was removed, and replaced 
next day ; union seemed firm. 8th, tube removed ; there was afterwards some trouble 
with the splints, which needed changing, and the wound on the 14th was no longer aseptic ; 
the tibia became displaced somewhat backwards and some fresh suppuration followed ; this 
was combated by making him lie on his face for half the day ; he slowly improved, and on 
October 16 the wounds were nearly healed, and he was sent to Convalescent Hospital. 
April 3, 1886, one sinus, the rest of the wound well shrunk ; not yet firm, but in good 
position ; fat and well. 

The treatment of the various joint affections can only be briefly given 
here ; it is impossible to mention all the applications and apparatus that 
have been devised. In acute 71011- suppurative joint affections of the upper 
limb, in the case of the shoulder, it is sufficient to strap the arm to the side, 
or, if the child is very young, to bind the limb with a flannel bandage across 
the chest ; lead lotion in infancy and an ice bag in older children is the only 
further application required. For the elbow nothing is better than a common 
inside or outside angular splint, which must reach from the axilla to beyond 
the end of the fingers ; all short splints, leaving the wrist and fingers free, are 
obviously insufficient. For the wrist a straight palmar or dorsal splint reaching 
from the elbow to beyond the finger tips should be applied. 

For the hip a Bryant's or Thomas's splint should be put on. For the 
knee and ankle the ordinary back splint with a foot-piece should be used, 
taking care that when the knee is the part injured the splint reaches well up 
to the buttock. A Thomas's knee splint answers excellently for all stages of 
knee-joint disease, but the child must of course be kept in bed for acute 
affections of the joints of the lower limb. 

When sicppuration occurs free incisions should be made into the joint and 
drainage tubes inserted ; where there is no previous opening, and the wounds 
are aseptic, washing out of the joint may be employed, and the wound then 
closed by sutures or the cavity may be drained, choosing a dependent posi- 
tion for the incisions, and avoiding the dangerous anatomical area of each 
joint. In sub-acute cases, with sero-purulent fluid or even pus in the joint, 
aspiration should be tried once or twice before free incisions are made ; but 
the joint must not be allowed to become distended with fluid, since this 
frequently leads to subsequent ligamentous weakness. 

In chronic non-purulent effusion, and in cases where a simple synovitis 
has left thickening behind, elastic pressure by a Martin's bandage lightly 
applied, or by common bandages applied over a thick layer of absorbent 
wool, does good service. Friction is often useful, and blisters frequently 
relieve pain and promote absorption. Care must be taken not to be misled 
by the presence of adhesions remaining after subsidence of disease into 
thinking that progressive mischief exists. A joint that has been acutely or 
subacutely inflamed, and after a week or two of treatment remains stiff, a 
little swollen, cold, and tender on pressure over one or two spots, with intense 

x x 



674 Diseases of tJie Joints 

pain at perhaps one spot on any movement beyond a certain point, though 
movement may be free tip to that point, is the seat of adhesions, and requires 
breaking down of these bands under chloroform. In such case-, inquiry 
should always be made to ascertain that there is no evidence of any tubercular 
taint before moving the joint. After breaking down adhesions the limb 
should be kept quiet for twenty-four hours and effusion prevented by pressure 
or cold ; and then, if all is quiet, both active and passive movement should 
be begun. While recognising the effect of adhesions in and about joints, it is 
well to remember that it is much less common to meet with cases of this 
kind among children than among adults or adolescents ; probably because 
the restless activity of childhood prevents the joint from being kept still after 
the acute and painful stage is over. 

When a joint has suppurated no premature attempts at procuring mobility 
should be made. As soon as the joint has been soundly healed for a 
week or two all apparatus should be left off, and the child allowed to try for 
itself — left, in fact, to do as it likes, in reason — it will seldom do too much. 
If after a few days no progress in mobility is being made, chloroform should 
be given and the joint carefully examined. It is generally possible to make 
out whether the adhesions are few and cordlike, or general ; in the latter 
case a permanently stiff joint will almost certainly result, in the former the 
adhesions should be at once broken down. Where a stiff joint is arranged 
for, the limb must for many months, often years, be provided with a splint to 
keep it in the desired position. Children's joints are very slow to ankylose. 

We have no great belief in inunction with Scott's ointment or oleate of 
mercury, and painting with tincture of iodine, as modes of treating chronic 
joint lesions, but pressure and friction are invaluable when acute mischief 
has subsided. 

In all cases of sy?iovial tuberculosis in the early pre-suppurative stages 
but one form of local treatment is, we believe, of much value — absolute 
fixation, with or without pressure. Where there is acute pain or a subacute 
attack in the course of chronic disease counter-irritants in the shape of 
blisters or the actual cautery are useful to relieve the pain, but we do not 
think they do any great good otherwise. We have tried and given up 
injections of iodine and carbolic acid into the pulpy tissue, and we cannot 
say we think Scott's dressing is of any great use, except as a means of 
pressure. For the upper extremity the plans mentioned for acute disease, 
combined with elastic compression, are all that is required ; for the elbow 
and wrist the splint may be made permanent by fixing it on with plaster of 
Paris, or substituting light iron strips in the plaster for the wooden splint, 
or a poroplastic splmt may be used. It is common to see figures of 
appliances for disease of the elbow and wrist in which the fingers are left 
free and can be moved ; this seems to us opposed to all principles of keeping 
the joints at rest, inasmuch as every movement of the fingers must necessarily 
disturb both elbow and wrist joints. The joints of the lower extremity must 
be considered more in detail. 

Injections of iodoform into tubercular synovial membrane is in some 
cases undoubtedly followed by local shrinking and cicatrisation of the 
tuberculous material. The effect is, however, very local, and the mode of 
treatment tedious and only applicable to a limited number of cases. 



Tuberculous Disease of the Knee Joint 675 

Treatment of Tuberculous Disease of the Knee Joint. — In early 
stages, where there is no dislocation and little flexion of the knee, the limb 
should be fixed upon a back splint with a foot-piece, and as long as the 
symptoms are acute the child should be kept in bed. If there is much 
flexion and pain the limb should be straightened gently under chloroform, 
and a splint then applied with an ice bag over the knee for the first twenty- 
four hours ; where there is flexion, but not much pain, an extension should 
be put on by a weight fixed with strapping below the knee, 1 or a Macintyre's 
splint may be used — we prefer the weight. As soon as the acute symptoms 
have passed off and the limb is nearly straight — it need not be quite so — a 
Thomas's knee splint with patten and crutches should be provided, and the 
child allowed to get about ; if there is much thickening, elastic pressure 
should be employed at the same time. Where the Thomas's splint cannot be 
obtained, or the friends cannot be trusted to look after the splint, or the child 
is too young to use crutches, a plaster of Paris casing should be put on, 
strengthened by the iron strips, as shown in fig. 151. As Mr. Paul of Liverpool 
has suggested, it is a good plan to cover the metal with rubber tubing. The 
child, if it is old enough, may get about with patten and crutches after the 
plaster of Paris is applied. Children under four years of age cannot usually 
be trusted to use crutches, and must be kept off their feet and taken out of 
doors in a perambulator or carriage. Cod liver oil and iron, careful dieting, 
and fresh, above all sea air — the great medicine for tuberculous bones and 
joints — should be the general treatment where possible. As long as there 
is no suppuration a fair trial should be given to the plan described; it is 
simple, and we know nothing better. There must be no taking off splints 
for washing or to see how the joint is getting on — one movement of a joint 
may undo weeks of rest ; leather and lace-up splints are for this reason not 
so good for hospital patients as plaster of Paris, though we greatly prefer a 
Thomas's splint where it is possible. Plaster of Paris has several objections ; 
it is messy to apply and impossible to keep clean, it conceals abominations 
of all sorts, it is apt to cause sores, it is heavy, it requires periodical 
renewals, it is prone to bring about a chronic venous engorgement of a part, 
which makes a limb flabby, and congested, and swollen, and ill nourished, 
and therefore slow in repair. In spite of all these objections, it is better to 
put on a plaster of Paris splint than to have a joint imperfectly kept at rest. 
Where the nurse can be trusted not to play pranks with the joint, such as 
allowing the child to bend it, or stand upon the limb, washing is a luxury 
that may be occasionally indulged in, but fixation comes first. If in spite of 
this treatment the joint gets worse, operation is necessary ; but in the case 
of the knee a very large proportion of patients will get better, and this 
because the disease is mainly synovial. 

When a joint such as the knee, in spite of efficient treatment for two or 
three months, steadily gets worse, pain and swelling increase, and the child's 
health begins to suffer, more active means must be taken, and these will 
become necessary much sooner in acute than in chronic cases. If the pulpy 
material is rapidly breaking down, and suppurating, and yet the child's health 
is keeping good, success is sometimes obtained by fixing the limb on an 

1 One pound of weight for each year of the child's age up to six years is a good general 
rule. 

x x 2 



6j6 Diseases of t/ie Joints 

interrupted splint, or better in plaster of Paris, and then opening and 
carefully draining the abscesses, taking care, if the whole joint cavity is 
suppurating, to drain at the back of the joint, or at the lowest point of the 
abscess sac if the suppuration is localised. By this means a certain number 
of these children will do well, and acquire sound, straight, and in some 
instances movable limbs. The plan is, however, only exceptionally appli- 
cable. If there is no suppuration, but the pulpy swelling increases, the best 
mode of treatment is Erasion. 

Erasion, or, as it is sometimes called, arthrectomy, consists in the case of the knee in 
opening the joint freely by a semilunar or other incision, just as in the ordinary mode 
of excising the knee ; the skin is reflected and the capsule removed on each side of the 
patella and patellar ligament, or, better, the patella is sawn across and the fragments 
turned upwards and downwards ; if necessary, free vertical incisions must be made to 
reach as high as the tipper limit of the synovial pouches. It is well not to dissect up the 
skin from the underlying tissue more than can be helped, as the pressure of the dressing 
which should be firmly applied sometimes interferes with the circulation in the edges of 
the wound and delays union. Next, every particle of pulpy granulation tissue is carefully 
cut away with scalpel or scissors ; all the infiltrated capsule and the semilunar cartilages 
are removed and the articular cartilage scraped quite clean, any granulation tissue being 
carefully picked out from pits in the cartilage, and, if necessary, any foci of disease in the 
bone gouged away. This process must be most thorough, and extreme flexion of the limb 
is required to fully expose and clean the back part of the joint ; the crucial ligaments are 
scraped, but if sound preserved ; the lateral ligaments are divided. The upper synovial 
sac must be thoroughly cleaned. The most difficult part of the operation is getting away 
the posterior part of the semilunar cartilages and the synovial membrane at the back of 
the joint. The process is a tedious one, often lasting one and a half or two hours, includ- 
ing the subsequent putting up in a splint. As soon as all bleeding has been stopped the 
limb is fixed on an excision splint and dressed in the usual method, antiseptically. Drain- 
age, if used, should be at the back of the joint on each side, the tubes being carried through 
openings made behind the joint, but in recent years we have used no drainage and closed 
the wound entirely. When this is done it is important to arrest all bleeding as perfectly 
as possible. Usually healing throughout by primary union is obtained. We prefer to 
Esmarch the limb, or at least put 'on an elastic tourniquet before beginning the operation. 
We usually put on a simple interrupted wooden splint at first, and in three weeks or so put 
on a Paul or Thomas's splint. For a series of cases vide Med. Chron. vol. ii. 1885. We 
introduced the operation in its complete form in January 1881, and the first case was that 
recorded and figured below.. The late Mr. Greig Smith, of Bristol, had, however, he told 
us, performed the same operation on an elbow in the previous year, but the case was not 
published until after our first case was recorded. There is, however, we believe, no doubt 
that Mr. Greig Smith was actually the first surgeon to perform erasion, though our case 
was the first published and his was unknown to us till long afterwards. We desire to give 
him full credit for his work. 

Case. — -Lizzie N., age 13 years 9 months ; old pulpy disease ; joint erased, all syno- 
vial membrane, much of capsule, semilunar cartilages, and a largish patch of carious bone 
removed, as well as a good deal of articular cartilage scraped away ; result, a perfectly 
movable, sound, painless joint, used as freely as the other ; ligamentum patellae not 
divided. She was under observation for nearly four years after the operation, and, except 
that she was liable to occasional serous effusion into both knees as a result of overwork, 
she remained well. The knee operated on differs little from the other except for the 
presence of the scar across it. In July 1889 this patient was again seen, and the knee 
remained perfectly sound and mobile. 

Erasion, we think, is applicable to cases of fairly early disease which 
have resisted efficient treatment by splints, &c. Though in the case recorded 
we obtained a freely movable joint, we have never had such a perfect result 



Evasion 



677 



since, nor do we think it wise to try for mobility, except in a few instances 
where the wound heals at once, and the adhesions are few. Erasion, if it 
fails, leaves the limb still fit for excision ; where it succeeds, the limb is as 
sound as after excision, but without shortening. 

The more we see of these cases, the more we feel sure that erasion is the 
proper operation, and that excision is hardly ever required, while the 
result is far better from erasion than excision. We prefer erasion, as above 
described, for the knee, but the general rules of treatment must, of course, 
vary with the particular joints, stability and absence of shortening being 
the cardinal points for the lower limb, mobility for the upper. Mere 
scraping through sinuses is of but little use, though if fistulas exist they 
should be well cleared out. ' Since the case above reported was operated on, 
many other ' arthrectomies ' have been performed, and, on the whole, with 





Fig. 148. Fig. 149. 

Show the condition of Lizzie N. after erasion, and the free mobility of the joint. 

very good results. Erasion is practically the only operation done at the 
Children's Hospital for tubercular disease of the knee. Excision and ampu- 
tation are almost unknown there for this joint. We have read many articles, 
some faintly praising, others condemning, the operation, and a few cordially 
advocating it. We and our colleague, Mr. Collier, have, provided the opera- 
tion is properly done, seen no reason to be dissatisfied with it, and can only 
venture to suggest that failure is due in some degree to incomplete operations. 

Should it be decided that the case is too far advanced for erasion, 
excision of the joint should be performed. We, however, have so seldom of 
late years found it necessary in children that details of the operation need 
not be given. 

As soon as the anaesthetic has passed off, opium should be freely 
1 Vide Rev. de Chir. March 188 z. 



6y8 



Diseases of the Joints 



given. 1 As soon as the wound is healed, or in less favourable cases as soon as 
only sinuses remain open, the limb should be fixed afresh in a plaster splint 
or put upon a Thomas's splint, and in about two months the child may be 
allowed to get about with a patten and crutches ; but the case is by no 
means done with, since nearly every case of excision, or of erasion for that 
matter, of the knee in children, unless thoroughly well looked after and a 
stiff apparatus kept constantly on for from two to four years, according to 
the child's age, will become crooked. Occasionally, after excision of the 
knee, a more or less movable joint has resulted, but we do not look upon 

this as an object to be aimed at, but 
rather as a failure of the operation, 
inasmuch as flexion and dislocation are 
likely to result where no bony union 
is obtained. Flexion, with dislocation 
backwards and outwards, is the com- 
mon deformity, but we have seen a 
general curve of the limb develop, or 
distortion at the epiphysial line of the 
tibia. This deformity is one of the 
great difficulties and drawbacks in 
excision of the knee ; the operation 
itself is not a very dangerous one : 
we did some twenty-five cases in 
children without a death, though some 
required subsequent amputation — this 
was the end of four of our first twenty- 
three cases. In recent years we have 
hardly ever excised a knee ; this 
operation has in our practice been 
almost entirely superseded by erasion. 
The amount of shortening resulting 
varies much : in three cases, after an 
interval of about three years, it ave- 
raged i \ inch. Though the results 
after excision of the knee are neces- 
sarily imperfect, it must be remembered 
that they are to be compared with 
prolonged suffering, danger to life, and amputation as the alternatives. 

Mobility after erasion is occasionally acquired and may be perfect. We 
are doubtful as to the desirability of trying to get it, and rather prefer to let 
the case take its own course and become mobile or remain stiff according to 
the degree of perfection of the joint. Our colleague, Mr. Collier, has tried 
by persistent movement of the patella to obtain a more mobile joint, but 
there is perhaps hardly time yet to estimate the value of the proceeding. 

In neglected cases of disease of the knee, even though the disease may 

have to a great extent subsided, the joint often remains flexed and subluxated 

to such a degree that the limb is nearly or quite useless. If there is well- 

1 in. i for each year of the child's age is the usual dose, and this should be repeated in 

an hour or more if required. 




Fig .150. — Shows the result of premature use 
of the limb after excision. The operation 
had been done at another hospital, and the 
patient was subsequently admitted under 
the care of our colleague Mr. T. Jones. 
There was bony ankylosis in the position 
seen in the figure, 



Deformity from Disease of Knee 



679 



f 



marked dislocation backwards, little can be hoped for in the way of reduc- 
tion ; all the tendons and ligaments become so shortened and contracted 
that, except in a recent case, little good can be done by extension or 
attempts at straightening — indeed, in some cases these attempts only make 
matters worse. Where there is flexion, but no, or only slight, displacement, 
extension by weights should be patiently used for some weeks ; if no result 
follows, chloroform should be given and an attempt made to straighten the 
limb by forcible, though not violent, manipulations, frequent extension and 
flexion movements being employed to break down any adhesions in or 
around the joint. Should it be clear that muscular 
contracture is an important factor in the resistance, 
the tight hamstrings should be divided, but we 
would dissuade from any violent efforts, especially if 
there has been much suppuration in the popliteal 
space : in such cases there is much risk of lacera- 
tion of vessels. Should the attempt succeed, the 
limb is brought straight, fixed upon a back splint 
for a day or two, and then an immovable appa- 
ratus or Thomas's splint applied. Joints will often 
straighten when somewhat flexed and even when 
slightly subluxated, merely by prolonged wearing of 
a Thomas's splint. 

Should it be found impossible to straighten the 
limb by these means, the choice lies between 
excision of the joint and osteotomy. We have 
employed both with good results, but they are ap- 
plicable to somewhat different conditions. Suppose 
the joint allows considerable movement although 
it cannot be straightened sufficiently to be of use, 
osteotomy is likely to leave an unsteady limb ; on 
the other hand, an acutely flexed limb requires 
removal of a very large amount of bone in excision 
before the leg and thigh can be brought into a 
straight line. We think, then, that osteotomy is 
best for cases of stiff joint with great flexion, excision 
for those where there is more mobility, less flexion, 
and more displacement. The late M. Beck and 

B. Pollard advocate division of the crucial ligaments with subsequent 
reduction in cases of subluxation, and have recorded a few cases ; we think 
the application of the method likely to be limited, since division of these 
ligaments certainly does not allow of reduction in all cases. 

Osteotomy in such cases is not a difficult operation ; a longitudinal in- 
cision is made about three or four inches in length on the front of the thigh 
from the patella upwards, the femur is exposed, and a sufficient wedge of 
bone removed from its anterior surface to allow the limb to be brought 
straight. We prefer this plan to simple section, which may cause dangerous 
pressure on the popliteal vessels and be followed by gangrene. In one of 
our cases after excision we could not nearly straighten the limb at the 
time, but by keeping up extension after the excision the limb was gradually 




Fig. 151. — Splint for disease 
of trie Ankle and Tarsus. 
It is made of iron, covered 
with india-rubber tubing, 
as suggested by Mr. Paul. 
The splint is fixed to the 
limb with plaster of Paris 
bandages. 



68o Diseases of the Joints 

brought almost straight. The following case illustrates the value of osteo- 
tomy in certain circumstances : 

Case. — Necrosis of Tibia. — Angular flexion of Knee. — Osteotomy. — Ralph II.. 
13 years ; admitted January 12, 1885. History good ; well till two years ago; complained 
of pain in knee, which soon swelled; no cause known; twelve months later had some 
(had bone taken from the leg ; discharge has continued till now. On admission, well- 
nourished boy ; was sent in for amputation ; the left tibia is enlarged and longer than the 
right ; on the inner side are scars of former operations, and a large sinus over the upper 
end of the bone ; the leg is flexed nearly to a right angle ; hamstrings tense ; toes pointed ; 
foot cannot be straightened. 24th, has had 6 lbs. extension on since admission, but the knee 
is no straighter. February 12, has had on a Thomas's knee splint since last note, and has 
been getting up ; no improvement. 13th, under chloroform an attempt was made to 
straighten the limb forcibly ; a few adhesions gave way, but no sensible improvement 
followed ; back splint. 20th, an incision 3 inches long was made in the axis of the femur 
above the knee, the periosteum was peeled back, and a large wedge of bone removed with 
an osteotome ; the limb could then be nearly straightened ; operation antiseptic. 24th, tube 
removed. March n, limb put up in back splint with movable foot-piece ; wound healed 
and limb straight. 20th, fair union of shaft ; leg straight ; foot in good position ; gets up 
with the Thomas's splint. Sent home on 24th. January 30, 1886, leg straight, walks 
without splint, sound and well ; toes still somewhat pointed. 

In another recent case the joint was much flexed, but mobile through a 
certain range ; on excising the joint it was found impossible to straighten 
the limb without greatly shortening it, so an osteotomy was done to the 
junction of the lower and middle thirds of the femur, and the limb was then 
brought into good position. 

Treatment of Pulpy Disease of the Ankle Joint. — The same general 
rules apply to the treatment of tubercular disease of the ankle as to that of 
the knee in the earlier stages of the disease, and many good results will be 
obtained by simple pressure and fixation. To carry out this plan the best 
means are to use either the apparatus shown in fig. 151, or a short metal 
back splint with a foot-piece, the child being allowed to get about with a 
Thomas's knee splint. Should suppuration occur, and the joint not recover 
by the means described, the prospect is a somewhat poor one : however, 
erasion and resection of the ankle for tubercular disease are now fairly 
satisfactory operations, though the disease sometimes spreads and amputa- 
tion is required. Amputation is, however, in these days almost a discarded 
operation, except at the hip joint, at least so far as the surgery of childhood 
is concerned. We did not amputate a limb at the Children's Hospital for 
joint disease during three years, except in one case where the mischief in the 
knee was the result of extension in a case of acute necrosis. A patient trial 
of fixation, pressure, and, if necessary, repeated removals of the disease 
should be given, even after suppuration occurs, provided the child's health 
is maintained, but the prospects of such cases in disease of the ankle are not 
nearly so good as in the knee. The following is an instance of a satisfactory 
result after erasion of the ankle : 

Case. —Peter H. , age 8 years 8 months ; admitted January 30, 1882. Ten weeks ago the 
right ankle became swollen ; no cause known ; had been treated with cold water, strapping, 
&c. ; never had much pain in it. On admission, fairly nourished but muddy-complexioned 
boy ; there was much swelling round the right ankle joint on all sides, with increased heat 
and redness on the outer side, but little or no tenderness to pressure, though movement 
of the joint was painful ; the circumference was an inch and three-quarters greater than the 
opposite side ; the position was semi-extended and rotated slightly inwards. On February 



Pulpy Disease of Ankle Joint 68 1 

9th the joint was opened Xyy a transverse incision (Mr. Holmes's plan) across the front of 
the joint dividing all the extensor tendons, <xc. ; much pulpy synovitis existed with ' sub- 
chondral caries ; ' all the pulpy tissue, as well as the loosened cartilages, was removed as 
far as possible, and a drainage tube passed across the joint, a groove being cut in the 
upper surface of the astragalus to prevent the tube from being nipped ; the tendons were 
then stitched together with catgut and the wound closed ; no attempt was made to unite 
nerves, and the anterior tibial artery was twisted ; sponge pressure was applied around the 
joint, and the operation was antiseptic ; finally the limb was fixed on a back splint with a 
foot-piece ; a little oozing followed at the first dressing ; on the following day the appear- 
ance of the foot was natural below the line of incision ; a little superficial ulceration 
occurred at the outer aspect of the front of the foot, and union of the edges was slow, but 
by March 13 the incision had healed except at the drainage-tube openings ; no pus had 
been discharged up to this date. On April 20 some sensation was perceived on the dorsum 
of the foot. There was no discharge, and on May 28 he was sent out with plaster of 
Paris over an Esmarch's splint and a sponge dressing still applied ; after this progress was 
very slow, some thickening remaining about the ankle, and occasionally a small part of 
the cicatrix would ulcerate and break down. February 1885, foot sound and well, but 
toes are somewhat pointed, and he ' throws ' the foot in walking. He gets about well with 
a boot and without any support. A good deal of new bone formation about line of incision, 
but some mobility. 

We have also had some excellent results after excision of the ankle. 

Case. — Disease of Right Ankle. — Necrosis of Astragalus. — Richard T. , age 4 years 
5 months ; admitted September 18, 1882. Family history good. History : Well till six 
months ago, when the ankle began to swell and has gradually got worse ; no pain ; no 
injury ; can walk. On admission, fairly healthy child ; somewhat rickety ; right ankle 
swollen ; bulging on each side of extensor tendons and round each malleolus, especially 
on inner side and in front of tendo Achillis. September 30, ankle joint aspirated ; a little 
serum drawn off, and some tr. iodi injected. October 20, no improvement ; an incision 
behind the inner malleolus gave exit to two teaspoonfuls of gelatinous and almost melon- 
seed-like material. October 28, wound healed; joint refilled. November 16, tempera- 
ture rose ; 104 "2° on 18th. November 23, joint opened ; a large, loose sequestrum of the 
astragalus was found and removed ; the whole astragalus was then taken away, and the 
lower end of the tibia and fibula resected, as well as the upper surface of the os calcis and 
the inferior tibio-fibular joint. The joint was opened by a transverse incision across the 
front ; the tibial and extensor tendons were stitched together afterwards. Operation anti- 
septic ; sponge pressure, and subsequently salycylic silk. January 13, antiseptics left off; 
had been doing fairly, but slowly ; still some^swelling. February 11, sent out in plaster of 
Paris over an iron splint round foot ; wound not healed. He finally got a good sound foot. 

If excision is performed the astragalus should always be removed entirely 
and all tubercular material taken away ; there is then a fair prospect of a good 
foot, and only when this fails should amputation be done. The prospects 
after excision are much better now than they were before recent improvements 
in the management of such cases. We have had some very satisfactory 
stumps after Pirogoff's operation, and watched them for years ; and, although 
it occasionally fails, where it is successful it gives a much better stump than 
Syme's amputation. If removal of the foot is too long postponed, disease is 
apt to spread up into the tibia and along the sheaths of the tendons, and then 
amputation higher up the limb will be called for : but the question of ampu- 
tation, as already pointed out, very rarely arises. (See also Treatment of 
Tarsal Disease.) 

In cases of tubercular disease of the ankle that resist treatment by other 
means v:e now usually excise the joint ; at least, we open the joint by the 
method described, remove the astragalus and all tuberculous material and 



684 Diseases of the Joints 

After total resection of the tarsus we much prefer to keep the foot in its 
natural position and allow the parts to adjust themselves, rather than arti- 
ficially produce a sort of equinus foot as proposed by WladimirofT. 1 

Disease of the phalanges and metatarsal bones of the toes differs in no 
way from the corresponding disease of the fingers, and requires the same 
management except that amputation may be resorted to in the foot earlier 
than in the hand, since 'the loss of a toe is of less consequence than that of a 
finger. 

Disease of the first metatarsal bone and of the metatarso-phalangeal 
joint of the great toe is common, and of importance, since it is liable to be 
followed by considerable lameness. Failing rest and general measures, the 
question of amputation or resection remains ; either is followed by a certain 
amount of crippling, but resection of the first metatarsal bone is so frequently 
unsuccessful that the most speedily satisfactory result is probably that of 
amputation. We usually resect the bone as a first resort, and only amputate 
failing this ; but we must confess that even when resection succeeds the toe 
is so shrunken and short as to be of little use. 

Sacro-iliac Disease is not very rare in children ; it is usually, we think, 
the result of extension of chronic tubercular disease from the adjacent bone, 
most often the ilium — at any rate, necrosis is common, and we have removed 
sequestra which included the articular surface of the ilium. The disease 
usually runs a chronic course, and gives rise to comparatively little pain ; 
often attention is first called to it by the presence of an abscess over the back 
of the joint ; sometimes, however, the matter forms at the intrapelvic surface 
and may point in the groin or track down behind the rectum : under such 
circumstances there may be pain down the leg from pressure upon the sacral 
nerves. Pain is sometimes felt in walking from the weight of the body bearing 
upon the diseased joint, and pressure directly upon the joint or upon the 
iliac crests, or, again, traction upon the iliac crests, tending to draw them 
backwards, gives rise to pain. It is occasionally possible to make out 
mobility of the ilium upon the sacrum, and we have seen displacement of 
the bones as a result of disease. Caries of the spine may cause sacro-iliac 
disease from the burrowing of pus into the joint, and in most of the cases we 
have seen there has been disease of bone or joints elsewhere. 

Sacro-iliac disease is best treated by rest in bed on a firm mattress, no 
sitting up being allowed. Should an abscess form and increase in size in 
spite of treatment, it should be opened and any diseased bone removed ; as 
soon as the acute symptoms, if any are present, have passed off, the child 
should have a double Thomas's hip splint applied : he may then be moved 
out of doors on a couch with safety. If the position of the abscess prevents 
the application of the splint in the ordinary way, the apparatus may be so 
arranged that on the affected side the splint is applied to the outer side instead 
of to the back of the limb {vide figs, in chapter on Spinal Disease). If the 
child recovers, there will probably be some arrest of growth of the pelvis on 
that side, and a lateral curvature of the spine. 

We have not seen a case of acute non-tubercular sacro-iliac disease, and 
the strength of the articulation is such that any acute traumatic mischief is 
unlikely to be met with. 

1 A paper by one of the present writers in the Med. Chron. 1886 may be referred to. 



Disease of Temporo-maxillary Joint 685 

Disease of the Temporo-maxillary Joint occasionally occurs in children 
as the result of scarlet fever, injury, or necrosis of the jaw or of the temporal 
or malar bones, or arises by extension from the ear, and gives rise to stiffness 
and inability to open the mouth, and later to distortion of the face from 
arrest of growth. Pain in movements of the jaw and swelling over the 
joint are the usual symptoms ; when suppuration occurs it usually points 
over the articulation. We have seen the joint suppurate in a case of 
pyaemia which was associated with acute suppurative arthritis in an infant. 

The treatment consists in opening the abscess, should one form, and 
feeding the child on soft food ; unnecessary disturbance of the joint is to be 
avoided. Should the jaw become stiff, attempts should be made to over- 
come the stiffness by means of a Maunder's screw, used several times daily 
after forcible opening of the mouth under an anaesthetic, just as in peri- 
articular adhesions from suppuration in the neighbourhood of the joint. 

Case. — Spurious Ankylosis of Jazv, tvilh Atrophy of the Bone. — Thomas C, age 
8 years 4 months; admitted June 21, 1882. Had 'low fever and inflammation of the 
lungs ' at two years old, and since then his jaw has been stiff, so that he lives on liquids 
and sop ; was thought to have hydrocephalus ; soon after he became ill he had otorrhcea, 
which continued until the time of admission with intervals. On admission was only able 
to open his mouth about a quarter of an inch ; nearly all his teeth were carious ; he spoke 
fairly well and seemed to be in good health ; the jaw was much atrophied, so that the 
upper teeth far overhung the lower ; the jaw was forcibly prised open under chloroform, 
and subsequently Maunder's screw was used, with the result of increasing his gape to 
more than an inch, and enabling him to masticate fairly well ; the use of the screw was 
continued up to February 1883. 

Failing this plan one of the forms of operation for the establishment of a 
false joint should be performed ; probably the most satisfactory in permanent 
results is resection of the head of the bone by an incision parallel to and 
below the zygoma, taking care to avoid injury to the facial nerve, but we 
have not met with a case requiring the operation. 

Disease of the Acromio-clavicular and Sterno-clavicular Joints is 
occasionally met with ; it should be treated by fixation of the arm to the side. 
If suppuration occurs the joints should be freely opened and the tuberculous 
material removed. We have found sequestra in the acromio-clavicular 
joint {vide General Surgical Tuberculosis). A certain amount of 
disability in use of the limb may result. 

' Hysterical Joints ' {vide chapter on HYSTERIA). — Though the utmost 
caution must be used before deciding that any joint trouble in children is not 
due to organic disease provided persistent complaint of the joint is made, it 
is an unquestionable fact that cases of so-called ' Hysterical joints ' are occa- 
sionally met with. We have seen children with such a condition affecting 
the spine and more rarely the hip. The great clue to the nature of the case 
is the incompatibility of the objective signs with the complaints made by the 
child. If with a history of long-continued complaints there is no local evidence 
of disease, and if the site of the alleged pain is inconsistent with the known 
nerve distribution, and if also the pain is exaggerated, we should carefully 
consider the possibility of a ' neurosis,' and this the more if the personal and 
family history supports such a view. We saw in 1895 a girl of about twelve 
years of age, who a fortnight after being sent to work complained of pain in 



686 Diseases of the Joints 

the hip and subsequently in the knee. She was supposed to be suffering 
from hip disease. On examination she was a stout, healthy, but excitable- 
looking child. She walked a little lame, and complained of pain in the region 
of the anterior superior spine of the ilium and in the knee. There was 
neither swelling nor rigidity of the joint, but alleged great tenderness on 
pressure. Further examination showed that pressure on various other points 
gave rise to extreme expression of pain, but by leading questions complaint 
could be elicited of pain in other parts of the body where there was no reason 
at all to suspect the presence of disease. The complaints were incompatible 
with what we know of organic disease, and the case was clearly shown to be 
hysterical. 



6S7 



CHAPTER XXXI 

HIP DISEASE 



Hip Disease x in the ordinary sense of the term — i.e. tuberculous disease 
of the hip joint — is almost entirely an affection of childhood ; thus only y$ 
patients, the subjects of this disease, were over twenty years of age out of a' 
total of 619 cases collected by ourselves, and probably in most of these the 
disease had begun in an earlier age. It is somewhat more commonly met 
with in boys than girls, and is much more frequent among the poorer than in 
the well-to-do classes. Mention has already been made in general terms of 
the pathology and causation of the disease : that the hip may be taken as the 
joint in which primary tuberculosis of the bones forming the articulation is 





Fig. 154. — Diagram showing at a, a (in ver- 
tical shading) the parts most commonly 
affected in Hip Disease, b is the trochan- 
teric epiphysis. The lower a points to the 
'calcar.' (Altered from Barwell.) 



Fig. 155. — There is a large sequestrum in the 
neck The head, which is still cartilage- 
covered but is almost detached, is propped 
up by a quill. Vascular perforations are 
seen in the marginal cartilage. Removed 
post mortem. 



most frequent. Indeed, our own belief, based mainly upon examination of 
some 150 cases of excision of our own, is that in true chronic, morbus coxas, 
such as we ordinarily see, and also in the acute and rapidly destructive cases, 
the disease begins almost invariably in the bone. In older patients a primary 
synovitis is more frequent, but in children an acute, subacute, or chronic 
inflammation of the upper epiphysis of the femur or its neighbourhood is by 
far the most common condition. In some cases the disease begins in the 
neck of the femur, and when this is so it is generally the under surface that 
is attacked, and this is the part on which the greatest strain comes in injuries 

1 For a more detailed account of Hip Disease in Childhood than space allows here 
the reader is referred to the monograph by one of the present writers : Hip Disease in 
Childhood, by G. A. Wright (Longmans & Co. 1887). Also to a work by Dr. R. W. 
Lovett of Boston, 1892. 



688 Hip Disease 

applied direct to the trochanter, and also the part least abundantly supplied 
with vessels (figs. 154 and 155). 

In some cases the disease is primarily acetabular, but much more fre- 
quently the initial lesion is femoral, though rapid destruction of the acetabulum 
may occur secondarily. In one hundred cases of our own the acetabulum 
was necrosed or perforated in twenty-seven, but in many of these the disease 
was probably primarily femoral. The part of the epiphysis usually first 
involved is the immediate neighbourhood of the epiphysial line. The occur- 
rence of synovitis of the hip joint is not, of course, denied by us, but we believe 
that two entirely different classes of cases come under observation : the one is 
a simple synovitis, usually traumatic, a lesion that occurs in the healthy and 
unhealthy alike, and is as amenable to treatment in the hip as elsewhere. 
The other class is one composed of tuberculous patients ; from some injury, 
or even slight overstrain only of the part, the cancellous tissue of the bone 
has its normal circulation slightly interfered with ; inflammation follows, and 
inflammation in a tuberculous subject is only too prone to follow the usual 
course of a tuberculous lesion, and the special anatomical features of the hip 
joint make it especially liable to serious and progressive disease. Necrosis 
of the pelvis or femur is common in the course of this disease ; thus in our 
first hundred cases of excision there were seventeen instances in which 
sequestra were found, either in or detached from the femur, and the aceta- 
bulum contained sequestra in twenty-two cases. 

The naked-eye characters of a typical specimen from hip disease in an advanced stage 
are the following : The cartilage is all gone or hanging in tags or worm-eaten plates, or 

it may be merely loosened and thinned with a layer of 
granulations underlying it (fig. 156) ; the synovial mem- 
brane is red and vascular, somewhat thickened, but rarely 
to anything like the degree already described in the case 
of the knee joint. The bone, as seen in section, varies 
somewhat, but certain characters are very constant. 
Sometimes the whole upper epiphysis is detached and 
forms a hard, loose, marble-like sequestrum ; in a larger 
number the upper epiphysis is destroyed to a greater or 
less extent : sometimes only a small part of it is actually 

Fig. i 5 6.-There is disease on § one - but in a11 h is of a dul1 yeUowish-white colour. In 

both sides of the epiphysial some late cases the colour is opaque, and the bone is 

line. On the under surface of putty-like, with or without obvious rarefaction ; in earlier 

££££&££>&5 — there is a ™« led appearance, patches of dark red 

the rim of the acetabulum. hyperaemic bone alternating with dull yellow areas, and 

There was pathological dis- here and there a soft patch of granulation tissue. Se- 
location. A section has been . ■, , ,, . , . ' 

made through the upper end questra maybe present, and the epiphysial cartilage may 

of the femur. be little altered, perforated, or entirely destroyed. 

Occasionally the disease spreads far down the shaft ; more commonly 
the bone below the level of the great trochanter is congested, with more or 
less rarefaction, but no extensive disease. Corresponding lesions are found 
in the acetabulum, which is often rough and eroded, and its walls absorbed, 
so that the cavity is wider and shallower than in health. Occasionally there 
is very extensive caries or necrosis of the pelvis, and, indeed, nearly the 
whole innominate bone may be diseased. It must be remembered that even 
when the pelvis is perforated there is a thick wall of dense fibrous material 




PLATE I. 




Hip Disease, with 'travelling acetabulum. 



Etiology and Pathology 



689 



intervening between the pelvic organs and the joint cavity, so that, although 
the bone is bare on both aspects, and much of it requires removal, there is no 
danger of injury to the viscera. The joint itself usually contains pus and 
false membrane, with broken-down caseous granulations and detritus. The 
conditions commonly found in the acetabulum have been already mentioned ; 
it should, however, be stated that in the later stages of the disease what is 
called 'travelling acetabulum' may be produced where repair to some extent 
is going on ; the rim of the acetabulum is destroyed by what looks like a sort 
of ploughing-up process, and when repair begins new bone is formed higher 
up on the dorsum of the ilium to form a socket for the end of the femur. In 
some instances the innominate may be separated into its component bones, 
as in two specimens in our collection. (See fig. 157.) 

In other cases suppuration may occur within the pelvis, either as a result 
of perforation of the acetabulum or of extension of inflammation through the 
thickness of the bone, or of pus, as it not 
unfrequently does, tracking over the brim 
of the pelvis and then gravitating down- 
ward. We have seen several cases where 
pus has burrowed up the sheath of the psoas 
and so got within the pelvic cavity. 

The remains of the head of the femur 
may lie in the little-altered acetabulum, or 
be drawn upward upon the dorsum, or even 
project through the acetabulum into the 
pelvis ; it has been found fixed to the ace- 
tabulum, though quite detached from the 
femur, or, rarely, firmly impacted, as we 
have seen it. The amount of acetabular 
disease depends, apart from the possibility 
of the orgin of the affection there, upon the 
fact that when once the joint cavity is in- 
volved, a large surface — i.e. the whole ace- 
tabulum — -is at once exposed to irritation, 
and so the process in it is more rapid ; it 
also depends upon how much the head of 
the femur has been allowed to press upon 
the pelvis. 

It is very rare to find any attempt at a 
new formation of bone while the disease is progressing, while, after removal 
of the upper end of the femur, new bone may be rapidly formed ; in this, of 
course, the hip resembles other joints. The rapid formation of new bone 
after excision is a strong indication for that operation, in that it shows that 
nature is unable to begin repair until the disease is removed. 

The etiology and pathology of morbus coxae, then, may be summed up as 
follows : 

1. Hip disease is dependent upon that deficient power of recovery and 
tendency to caseous degeneration which may be called the strumous or scrofu- 
lous, or, better, the tuberculous diathesis, and this constitutes the predisposing 
cause. The disease is, in fact, a local tuberculosis. 

Y Y 




Fig. 157.— Shows extensive Acetabular 
disease. The ilium is completely de- 
tached from the other two bones, and 
is largely necrosed ; white scale-like 
patches of new bone are seen on the 
surface. The disease was acute. 



690 Hip Disease 

2. Any slight or severe injury, over-use, &c, or the onset of a specific 
fever, may, in such a constitution, prove an exciting cause. 

3. Injury in a healthy child may produce synovitis, or even acute inflam- 
mation of bone about the hip, as elsewhere, but this does not, except very 
rarely, lead to chronic hip disease. 

4. In the vast majority of the cases of morbus coxae the disease begins 
as an osteomyelitis of the upper epiphysis of the femur, or of the immediate 
neighbourhood of the epiphysial line, or not very rarely of the acetabular 
epiphysis. 

5. This particular osteomyelitis tends to destruction, and usually runs a 
chronic course with caseation of the inflammatory material, and resolution 
can rarely, if ever, be expected when the disease is well established. 

6. The occurrence of the disease in childhood is explained by the physio- 
logical and anatomical peculiarities existing before puberty. 

Besides the common chronic hip disease, there is a form of acute hip 
disease which may run its course in a few weeks, or even days, and produce 
as much or more destruction of parts than months or years have in the chronic 
cases. Instances of this condition are not very rare ; every hospital surgeon 
sees them occasionally. Some of these cases are probably pyaemic, others 
belong to the class of ' acute suppurative arthritis of infants ' {vide p. 670) ; 
others, again, are acute traumatic inflammation, synovial or osteomyelitic ; 
possibly in some partial separation of the upper epiphysis may occur, with 
rapid necrosis ; others, again, are probably cases of acute periostitis of a 
nature similar to that occurring in the shaft of the femur, tibia, &c. These 
last may result in widespread suppuration and necrosis of the pelvis and 
femur. An acutely destructive condition may come on in the course of 
chronic disease. 

Lastly, acute tuberculosis sometimes leads to rapid suppuration. 

Symptoms. — In describing the symptoms of hip disease it will be con- 
venient to take them one by one, and discuss the views and explanations of 
each symptom before passing on to the next, and finally to group them 
together in a type case. 

Pain. — Pain is a prominent feature of most cases of hip disease from the 
beginning ; at least until complete disorganisation of the joint and displace- 
ment or destruction of the head or recovery. 

The seat and degree of pain are, however, alike very variable. Thus 
pain may be referred to the hip itself, the buttock, the back or front of the 
thigh, the knee in front or behind, or any part of the leg or foot. It may be 
localised or diffused, so that the patient strokes the whole thigh down in 
some cases when asked where his pain is, and but rarely points to any one 
spot. There is no consistent relation to be made out between the seat 
of pain and the position or extent of disease. Probably the front and 
inner side of the knee is the most frequent seat of pain. Tenderness, 
however, is often much more localised to the position of the joint, but 
even that is very variable. Pain is, undoubtedly, often remittent ; some- 
times an interval of some weeks intervenes, even without treatment, 
between the attacks. We have seen cases where the child had been walking 
about with a shortened, distorted limb, who never had any pain from 
beginning to end ; and others, with large abscesses, who have also been 



Pain in Hip Disease 691 

throughout free from pain ; while the agonising pain of those who have to 
endure 'night startings ' is only too familiar to all who have been residents 
in hospitals. 

In considering the question of pain, it is well to bear in mind the number 
of different sources of nerve supply to the joint. 

It is not practicable, nor very important, to distinguish by a knowledge 
of the nerve distribution the exact patch of synovial membrane or ligament 
that is locally inflamed : its only value, if it were possible, would be from a 
prognostic point of view ; but here history, duration, and other symptoms 
are more trustworthy. There is, however, no doubt that ' night pains ' give 
us evidence of extension of the disease to the articular surface. 

It is, then, clear that pain in cases of hip disease is variable in its seat, 
or rather that it may occur in a great many different places ; of these, 
special attention has always been paid to pain in the knee, and several 
explanations are given of this pain. In the majority of cases it is probably 
due to ' transferred sensation ' from one of three sources, the anterior crural, 
the sciatic, or the obturator nerves, branches of which are distributed to the 
front and back of the joint. In our experience, the pain in the knee is generally 
rather vaguely referred to the front of the knee, the child passing its out- 
stretched hand over the whole of the front of the joint. The pain, in fact, is 
referred rather to the distribution of the anterior crural than of the obturator. 

Pain in the hip is not usually a marked sign in the sense of there being 
any constant pain ; tenderness on pressure over the front or back of the 
capsule, and pain in pressing the trochanter inward or the head of the bone 
upward, is, of course, present in all acute cases, and a large proportion of the 
chronic ones. 

Night startings or pains are a prominent and important feature in acute 
and subacute cases ; they may be altogether absent in chronic disease — 
except where acute mischief has supervened upon chronic — and they may 
be absent throughout the whole course of a case. When they do occur, 
they indicate that inflammation has extended to the joint surfaces ; and 
further, that our means, whatever they may have been, of treating the lesion 
have been inefficient so long as these startings continue. Their cause is too 
well recognised to need discussing. The rigid muscles, acting under the 
influence of 'joint sense ; (Barwell), contract spasmodically to fix and 
immobilise the joint surfaces ; as sleep comes on, with its accompanying 
muscular relaxation, some friction or pressure of the tender surfaces together 
takes place, causes acute pain, a sudden awakening with a cry, and a violent 
spasm of the muscles to again fix the joint. This may be repeated many 
times in a night, and is a strong indication for treatment. These night 
pains are very uncommon after excision : where they do occur they mean 
that disease is extending in the pelvis, and probably the femur is not kept 
sufficiently far away from the acetabulum to prevent pressure upon it ; in 
such cases, then, it is well to increase the extending force, though in some 
cases too great extension may increase pain. Tenderness or pain on 
pressure has been already alluded to. When superficial tenderness really 
exists, the fears of the child, if he has already been ungently handled, being 
taken into account, it means that suppuration has occurred in the soft parts 
and is becoming superficial, or, in very acute cases, it seems that really all 

Y Y 2 



692 Hip Disease 

the parts in the neighbourhood of the joint are hyperaesthetic ; it is certainly 
the case that in no joint does inflammation extend so widely among the soft 
tissues as in hip disease. 

When, however, no pain is produced, except on deep pressure applied 
over the head of the bone, it is probable that the disease is limited to the 
bone, and has not yet set up mischief of any serious nature within the joint, 
or, at least, that any such change is a very chronic one. It is well to bear 
in mind that pressure on an inflamed ligament is very painful indeed — a 
fact easily verified in chronic synovitis of the knee — and it is possible that 
the pain in these cases may be due to extension of the disease to the capsule 
rather than to the inflammation in the bone itself. 

Certain movements of the joint are more painful in case of inflammation 
than others, and it is true that a patient may have quite or almost painless 
power of flexion of the joint, and yet be quite unable to bear rotation or 
abduction. 

Night startings may exist and be due to hip disease without any 
recollection of pain on awakening ; but Howard Marsh cautions us against 
mistaking the cries of nightmare for those of night starting. 

It is well to remember that inflamed inguinal or iliac glands may cause 
pain and tenderness, which must be distinguished from that of the joint itself. 

Lameness. — Limping or lameness is the symptom usually first noticed by 
the parents in the case of children with chronic hip disease. Even this, 
however, may be preceded by a feeling of tiredness or ill- defined aching 
about the limb after exercise, the aching passing off after rest, but recurring 
again after less and less exertion. The limping may be quite painless at 
first, and differs in appearance from the well-marked ' drop ' seen in later 
stages, when there is shortening of the limb. At this time the child generally 
shows a tendency to rest the affected leg, and throw the weight upon the 
sound limb at every opportunity. Later, well-marked lameness comes on, 
and is accompanied by pain. It is at this time that the mistakes in diagnosis 
are so often made ; the obvious symptoms are lameness, and often pain in 
the knee or thigh ; there is no other marked sign, and the condition is sup- 
posed to be disease of the knee or ' weakness ' with ' growing pains, : and so 
on. This stage requires careful and exact investigation to discover it, and 
at the same time is the period at which treatment is most effectual. Later 
in the disease lameness is due either to actual shortening, or to tilting of the 
pelvis to take the strain off the tender limb, or to flexion. 

Heat. — Increased temperature in the joint is, of course, only perceptible 
where the inflammation is acute, and from the thickness of the parts cover- 
ing the joint is not readily ascertained ; it is not, therefore, a symptom of 
much value, except in the third stage, where superficial swelling combined 
with heat indicates the presence of suppuration outside the joint. In some 
cases of acute synovitis, pure and simple, a local rise of temperature may 
be made out, and is a valuable indication of acute inflammation of the soft 
tissues. 

Swelling. —Swelling is one of the most important symptoms. In the 
first place, local swelling over the front and back of the joint — i.e. just 
external to the femoral vessels or pushing them forward, and just behind 
the trochanter, obliterating the normal hollow — indicates effusion into the 



Muscular Spasm— Rigidity 693 

synovial sac, and, with a recent history of injury, indicates an acute synovitis. 
With a longer history such swelling is due to the secondary inflammation of 
the joint by extension from osteomyelitis. 

Swelling of the great trochanter indicates suppuration, or rather caseation 
within the joint, and when well marked we believe may be relied upon as 
pathognomonic of it : it is true that this thickness may disappear under 
treatment, but none the less has there been puriform material there which 
has been absorbed as far as its fluid portion goes, and if once that thickening- 
has occurred we do not think any case is free from danger of relapse. This 
thickening results from extension of the disease from the interior of the bone 
to the surface. 

Periarticular or ' adjacent ' abscess certainly does occur, but not so 
commonly, we think, as some writers describe. Swelling of the inguinal 
glands is considered by Mr. Barwell to indicate osteitis. We would go even 
farther, and say that when considerable it often indicates disease of the 
pelvis rather than of the femur. It is common to find some enlargement of 
inguinal glands in tuberculous children, but we think they seldom suppurate 
unless the pelvis is diseased. The condition of the iliac glands will be 
noticed again. 

Muscular Spasm. — Spasm of the muscles around the hip is, as in the 
case of other joints, an almost universal condition — quite universal, if we 
except those cases of osteomyelitis where the inflammation is as yet limited 
to the bone, and the few cases where the joint is slowly and painlessly dis- 
organised — cases already alluded to under the section of Pain. 

The spasm is due, as is well known, to two causes : reflex spasm from 
irritation of the terminal nerve filaments supplying the articulation, the 
stimulus being reflected in accordance with Hilton's laws to the muscles 
moving that joint — BarwelFs 'joint sense ;' and secondly, a voluntary con- 
traction of the muscles to prevent movement of the painful surfaces the 
one upon the other. 

It is well known to what the particular position of the joint in disease is 
due ; flexion and abduction, as long as it remains a closed cavity, is the 
position of least tension, and therefore of least pain ; the aggregate mass of 
flexors, too, is stronger than the extensors here as elsewhere, so that flexion 
is the position of rest. 

The rigidity of the spasm is very great indeed, so much so that in many 
cases, without painful manipulation, it is impossible to say from mere 
physical examination that the joint is not ankylosed. In most cases, how- 
ever, there is a certain limited range of movement allowed through, perhaps, 
io° in the middle of flexion, and in many cases a considerably larger range, 
while in some it is only in extreme flexion and extension that spasm exists. 
Nocturnal spasm has already been alluded to under the section of Pain. 
Fixation or Rigidity. — Fixation of the joint, apart from muscular spasm, 
may depend upon any one of three causes, but can only exist in the second 
or third stage of the disease, or as a result of quiescent or cured disease. 
The causes are adhesions within or around the joint, matting together of 
muscles so that their power is lost, or bony ankylosis. Chloroform at once 
reveals the nature of the rigidity, whether it is due to mere muscle spasm, 
when, of course, it will disappear ; or to adhesion or permanent muscular 



694 



Hip Disease 



contracture, when it can generally be sufficiently overcome to show that 
there is no bony union of the parts. 

Grating or Crepitation. — Grating felt on movement of the hip joint can be 
produced by one cause only, the presence of exposed bone. This may be- 
due either to erosion of cartilage allowing the bare head of the femur to grate 
against bare acetabulum, or to sequestra grating against one another, or to 
the upper end of the femur rubbing against its own bare and detached head. 
It is, therefore, where it can be felt, an absolute and pathognomonic indica- 
tion of the presence of dead or carious bone. But it must be remembered 
that it can usually only be obtained under an anaesthetic, when free move- 
ment without pain can be procured. 

Abscess. — The vast majority of cases of hip disease, unless seen in the 
early stage and adequately treated, go on to suppuration. A certain number 
of cases get well by the process of removal of the inflamed end of the bone 
without suppuration — a caries sicca ; but the greater number by far go on to 
the formation of pus. Yet of this number by no means all develop abscesses 
which open and discharge externally. Suppuration within the cavity of the 
joint takes place and even bursts the capsule, and yet, by absorption of the 




Fig. 158. 



-Showing the extreme Lordosis produced by partial correction of the deformity 
in a case where rectangular flexion existed. 



fluid and removal more slowly of the solid elements, the swelling caused by 
the abscess may disappear and the case recover. Still, we are convinced 
that nearly every case of chronic disease of the hip, if not cured in an early 
stage, would be found, if the joint were examined, to contain pus or puriform 
liquid at a certain period of its course. 

When the joint cavity suppurates the pus may take very various courses 
after it has burst from the joint, but usually it issues at the posterior part, 
sometimes on the inner, sometimes on the outer side. It may then pass 
forward beneath the rectus femoris and point at the anterior border of the 
tensor vaginae femoris ; it may travel down the thigh and point at a lower 
part of the edge of this muscle ; it may gravitate backward and open at the 
upper or posterior border of the great trochanter, or, farther still, at the 
lower border of the gluteus maximus ; it may reach to the perinaeum, extend 
along the adductor tendons, and come to the surface at the inner side of the 
thigh ; or, again, it may pierce the skin just at the inner angle of the fold of 
the groin between the scrotum or labium and the thigh. It may travel up 
the sheath of the psoas and point above Poupart's ligament, or, travelling 
over the brim of the pelvis, may then gravitate downwards and burst into the 
rectum or the ischio-rectal fossa, or escape through the sciatic notch. We 
have records of two cases where pus was discharged through the rectum, and 



Wasting — Outfate 69 5 

we- are inclined to think it is commoner than is supposed, and that the dis- 
appearance of abscesses about the joint is sometimes to be thus accounted 
for. A bad result does not necessarily follow, and some cases are probably 
glandular abscesses not directly connected with the joint ; in other instances 
faecal matter has been discharged into the joint. 

Abscesses in the neighbourhood of the hip not due to disease of that joint 
must be carefully distinguished from those which either directly communicate 
with the joint cavity or result from the breaking down of tubercular matter 
in the walls of the articulation. 

From the cases we have watched we think the conclusion may be drawn 
that when an abscess points on the front of the limb, above a line drawn 
through the upper border of the great trochanter, there is disease of the 
pelvis, and this is the more certain the higher and the more internal the 
opening. Abscess pointing between the scrotum and labium and the thigh we 
always look upon as of serious import, indicating pelvic caries. The peculiar 
conical projection to be felt on pressure above Poupart's ligament, as pointed 
out by Barwell, is rather due, in our opinion, to enlargement of the iliac glands 
than to periosteal pelvic thickening in many cases ; like thickening to be felt 
by rectal examination at the site of the acetabulum on the inner wall of the 
pelvis, it is to be looked upon as a grave sign and one pointing to marked 
pelvic disease, and, as already stated, suppuration of glands is also suggestive 
of acetabular disease. 

Wasting of Limb. — Muscular wasting of the affected limb is an early 
and prominent condition in hip disease — -so early and so rapid that it is, and 
with good reason, ascribed to the result of trophic nerve changes rather than 
to mere disuse. The limb in later stages assumes a peculiar bulbous look, 
the thigh and leg are small, thin, and weak, while the hip itself is rounded, 
swollen, and distended as compared with the opposite side, and coldness 
and venous congestion are commonly present, often with oedema of the foot 
from venous or lymphatic obstruction. The bone, too, undergoes a great 
amount of atrophy, the denser layer is thinned, and the spaces of the cancel- 
lous tissue enlarged, so that the bone becomes diminished both in diameter 
and strength. Such is the condition which has in several cases led to frac- 
ture of the bone in attempts at thrusting the upper extremity out of the 
wound in the operation of excision, and this is a fact to be remembered in 
the forcible straightening of the limb. 

Arrest of growth under such circumstances is to be expected, and does 
occur, but to a much less extent than would be imagined, as will be seen in 
the section on Results of Excision. 

Outline of Region of Hip. — Two points are always described in con- 
nection with disease of the hip as being characteristic of it — loss of the 
fold of the groin, and flattening and widening of the buttock with lowering 
and partial obliteration of its fold. These conditions are worth noting, 
although they are not always present, nor always characteristic of hip disease 
when they are present. The fold of the groin is most completely obliterated 
when the limb is abducted and rotated out, especially if there is also swelling 
of the front of the joint or glandular enlargement. On the other hand, the 
fold is exaggerated in adduction and rotation inwards ; in this position in girls 
the labium will be compressed, flattened, and partially or entirely hidden. 



696 



Hip Disease 



The rima natium is inclined upwards and towards the diseased side, 
which is simply the appearance produced by lowering of the buttock in the 
second stage ; in the third it of course takes the opposite direction. 

Dislocation and shorteni7ig. — The older writers on hip disease spoke 
of dislocation as one of the common results of the destruction of the joint. 
Probably they were misled, in the absence of actual dissection, by the 
shortening, adduction, and inversion of the limb which occur in the third 
stage. 

As a matter of fact it is probable that without injury true dislocation of 
the head of the femur out of the acetabulum very rarely occurs. Several 
conditions may exist and give rise to the appearance of dislocation, the 





Fig. 159. — Shows the position assumed in 
the second stage of hip disease. Flexion, 
abduction, rotation outwards, apparent 
lengthening. Right hip disease. 



160. — A side view of fig. 159. 



most common being destruction of the head of the femur ; the truncated 
upper end of the bone is then drawn upwards by the muscles attached to 
the trochanters, so that the upper border of the great trochanter rises above 
Nelaton's line : here, as the head of the bone no longer exists, true disloca- 
tion can hardly be said to have occurred. Occasionally, however, true dis- 
location of the head of the femur on to the dorsum does occur — we have met 
with several instances of it. 

Apparent lengthening of the limb is due to a lowering and throwing for- 
ward of the pelvis on the affected side ; apparent shortening, on the other 
hand, to the pelvis being raised and thrown behind the sound side. Or, to 
take the same fact in another way, the apparently lengthened limb is flexed 
and abducted, the apparently shortened limb is flexed and adducted, the 



Diagnosis 697 

two conditions being usually, but not always, associated with rotation out- 
ward and inward respectively. 

Taking the usual classification of the course of the disease into three 
stages, the position assumed successively by the limb will be — in the first 
stage, flexion to a variable degree, with or without slight abduction, and 
possibly rotation outward ; in the second stage, flexion, usually well marked, 
with abduction usually, and rotation outward, producing apparent lengthen- 
ing — sometimes, however, there is adduction, and sometimes mere flexion, 
with no rotation, or with rotation inward ; in the third stage there is always 
flexion, and most commonly adduction and rotation inward, with apparent 
or real shortening, but there may be abduction and rotation outward. Thus 
position, though a valuable, is not an absolute guide, and requires to be 
checked by the only symptoms present. 

Diag?iosis. — The diagnosis of disease of the hip is as difficult in some 
cases as it is easy in others. In well-marked cases where the disease is 
advanced it usually is quite readily diagnosed, while, on the other hand, few 
diseases are so closely simulated by a large number of other affections as 
disease of the hip, and the variety of symptoms that it presents is in itself a 
fruitful source of mistake. It will, perhaps, most conduce to a clear under- 
standing of the subject if we first tabulate the diseases for which hip disease 
is most likely to be mistaken. 

1. Acute rheumatism. 

2. Bursitis of the psoas or one of the gluteal bursae. 

3. Ostitis or periostitis of the great trochanter. 

4. Periostitis of the upper end of the femur. 

5. Sacro-iliac disease. 

6. Psoas abscess. 

7. Iliac abscess. 

8. Gluteal abscess, traumatic or spinal. 

9. Abscess connected with disease of the pelvis. 

10. Perityphlitic abscess, suppuration around the sigmoid flexure of the 
colon, pelvic glandular abscess, or chronic adenitis, or possibly renal disease. 

11. Superficial abscess, glandular or other, and deep abscess around the 
ioint. 

12. Infantile paralysis. 

13. Syphilitic synovitis or telostitis. 

14. Hysteria. 

15. ' Congenital dislocation' of the hip, or other congenital conditions. 

16. Rickets, including coxa vara. 

17. Disease of the knee. 

18. Fracture of the neck of the femur, separation of the upper epiphysis 
or dislocation. 

19. Acute synovitis. 

Of these diseases only a few of the more important need be selected 
here. Inflammation of the gluteal bursa?, of which that between the gluteus 
maximus and the great trochanter is the most commonly affected, may 
simulate hip disease. In this case a large gluteal abscess may be mistaken 
for abscess connected with the joint, or if the abscess has burst the long 
track left may lead upwards, and be indistinguishable from one com- 



698 Hip Disease 

municating with the joint ; the absence of shortening, of adduction, or of 
grating on movement of the joint, which will also move freely through a 
certain range, absence of pain on jarring or pressure, and of fulness in front 
of and behind the joint, are the diagnostic points. 

Disease of the great trochanter is more difficult to distinguish, and it must 
be remembered that inflammation may extend from the shaft to the joint ; but, 
although in trochanteric disease sinuses may exist in the same positions as 
those in which they are found in morbus coxae, the smoothness and freedom 
from grating, as well as the wide range of mobility of the joint, will serve to 
distinguish between the two ; other abscesses in the neighbourhood of the 
joint are recognised by their history, which is usually too short for Chronic 
hip disease, and not acute enough or sufficiently severe for acute joint in- 
flammation. They are also recognisable by the freedom and smoothness of 
the movements of the joint through a certain range, even though that range 
may be a limited one. Absence of pain and tenderness in some part of the 
joint circumference will be contributory evidence. 

Infantile paralysis simulates hip disease in the lameness to which it 
gives rise, but is distinguished from it by the absence of pain and swelling, 
and especially by freedom of mobility, and by an amount of wasting and 
coldness of the limb disproportionate to the other symptoms, as well as by 
the history of the disease ; it is, however, worth noting that in the ' British 
Medical Journal ' for 1877 Mr. Savory records a case of acute hip disease in 
a leg affected by infantile paralysis. 

Syphilitic disease is distinguished by other evidences of syphilis, by the 
slight tendency there is to suppuration, and by its amenability to mercurial 
or iodide treatment. We have, however, seen chronic hip disease in a con- 
genitally syphilitic child. 

Sacro-iliac disease and psoas abscess may both simulate hip disease in 
regard to the position in which they give rise to pain, and as to flexion of the 
joint ; it is, however, only necessary to examine the spine and sacro-iliac 
articulations to find in most cases symptoms incompatible with disease of the 
hip alone, while in simple psoitis flexion and inward rotation are free. 

It must be remembered, at the same time, that the abscess within the 
psoas sheath, resulting from either of these diseases, may open into the hip 
joint, and so a secondary hip disease may be developed. It is not, we 
believe, very rare for psoas abscess to do so ; and, although we have only 
had one opportunity of verifying the fact post mortem, we have in several 
instances believed such to be the case. Spinal caries and hip disease may, of 
course, coexist independently of each other, and this is not rare. It is some- 
times impossible to be sure that disease of the hip does not exist where an 
iliac or psoas abscess has burrowed down and surrounds the hip joint on all 
sides ; the symptoms are then often identical, and only the discovery of 
the spinal or iliac disease can clear up the case. In other instances free 
mobility of the joint through a certain range in all directions excludes hip 
disease. Rectal examination enables us to distinguish between hip disease 
and spinal gluteal abscess, since in the latter the abscess can be felt to 
extend upwards over the brim of the pelvis. 

Abscess connected with the caecum, or sigmoid flexure, is not uncommonly 
mistaken for hip disease. Such cases closely resemble iliac abscesses from 



Diagnosis 699 

other causes, with the addition of symptoms indicating connection with or 
proximity to the large bowel. 1 

Congenital atrophy of the femur is not likely to be mistaken for recent 
disease, but may, perhaps, be a result of intra-uterine affection of the 
joint. 

One of the commoner sources of error is enlargement of the iliac or of 
the inguinal glands ; pain, lameness, flexion, and some rigidity of the joint 
are found ; on examination by deep pressure above Poupart's ligament the 
enlarged glands may be felt, and palpation is painful ; careful search, how- 
ever, will show rigidity only in extension or slightly in abduction as well, 
while flexion, abduction, and rotation are free ; there is no trochanteric 
thickening and no evidence of effusion into the joint. It must be remembered 
that the glandular enlargement may be due to hip disease itself. 

It is always well to use the ' method of exclusion ' in doubtful cases, and 
to bear in mind that there is no one symptom pathognomonic of hip disease, 
but that, as in other morbid conditions, several factors have to be taken into 
account in forming a diagnosis. Free, smooth, painless mobility is perhaps 
the most satisfactory evidence- of the abse?ice of hip disease. 

To sum up the diagnostic points of hip disease. A patient who is a child, 
who walks lame, especially after a little exercise, who has thickening of the 
trochanter, some tenderness on pressure over the hip joint, and pain together 
with slight flexion and some immobility of the joint, without evidence of 
spinal or sacro-iliac disease or pain in any part higher than the hip, and in 
whom pain is increased by abduction or rotation inwards, has got disease of 
the hip. We would here lay stress upon the fact that there is not the smallest 
necessity for hurting a child in an examination for hip disease. It is true 
that pressure upon the trochanter or heel, what is expressively called by 
American surgeons ' crowding the joint surfaces together,' gives rise to pain 
in disease of the joint, but it is neither a necessary nor a pathognomonic 
sign. Night starting is a valuable, but not a constant nor always trustworthy, 
symptom. Later in the disease the problem is usually easily solved, but 
not always, for, as indicated above, disease of the trochanter or abscess 
around the joint, as well as bursitis, may resemble hip disease very closely ; 
in such cases the position and swelling of hip disease, as well as its rigidity, 
are very closely simulated, and we must rely on other points. Such condi- 
tions can, however, only be mistaken for the later stages of the disease, in 
which there will be shortening of the limb, raising of the trochanter, and 
probably grating in the joint if examination is made under chloroform. It 
is only occasionally that we see a child in quite the first stage before the 
mischief has reached the surface of the bone ; in such case pain, lame- 
ness, slight flexion, and slight rigidity are the principal signs. Usually the 
patient is brought in the early second stage, when trochanteric blurring is 
found. 

Believing, as we do, that chronic hip disease in children begins invariably, 
or nearly so, as an osteomyelitis, we cannot follow Harwell's distinctions in 
the diagnosis of this condition from synovitis ; but see p. 690. We do, 
however, think that acute synovitis can be distinguished from the early 
1 Vide paper ' On Some Forms of Abdominal Abscess occurring in Children,' by 
G. A. Wright, in Arch, of Pediatrics, 1884; also Lancet, 1890. 



700 Hip Disease 

stages of true hip disease by the greater pain on movement of the joint, with 
absence of trochanteric thickening, and under chloroform free and perfect 
mobility; there may be also swelling in front of the joint, but this depends 
upon the amount of the effusion. In simple traumatic synovitis the mischief 
immediately follows the injury, while in the bone lesion there is usually an 
interval of two or three weeks, or often months, between the accident and 
the onset of symptoms ; thus the child falls, cries for a few minutes, but is 
then well again, and in a month's time begins to limp. This evidence of the 
history is most important. Careful inquiry should always be made in every 
case for any previous trouble about the hip, since the acute symptoms may 
be grafted upon old latent disease. 

Acute osteomyelitis is readily diagnosed ; great constitutional disturbance, 
fever and prostration, great pain, amounting to agony on the least movement, 
helplessness of the li?nb, rapid and extensive swelling, with venous turgidity, 
make the diagnosis easy. 

Mr. Howard Marsh, in his valuable paper in the ' British Medical Journal : 
for 1877, gives us most useful information on the diagnosis of hip disease. 
Thus, he points out that, though flexion may be free in some cases, the 
flexed limb is carried into abduction, and not straight up towards the 
abdomen ; again, flexion may be limited in cases of gluteal, or extension in 
cases of psoas abscess, but in hip disease both are limited in their more ex- 
treme degrees, even if free in part of the range of mobility. His caution as 
to the dangers of frightening the muscles into spasm is also well worth 
remembering. In examining children it is always wise to manipulate the 
sound limb first, as this gives the child confidence that he is not going to be 
hurt, and he is less likely to voluntarily hold the joint stiff. Rectal examina- 
tion for thickening of the inner wall of the acetabulum we have occasionally 
found of value in doubtful cases, and it certainly should be employed if there 
is any suspicion of primary acetabular disease ; under such circumstances it 
may be the only way to clear up the doubt. An excellent account of it is 
given in Dhourdin's work, ' De la Coxalgie Cotylo'idienne.' 

In examining a child for suspected hip- disease in an early stage the 
course of procedure should be as follows. First, the child's confidence should 
be gained, so that it will not be afraid ; next, all clothing should be removed 
and a blanket wrapped round the patient, who should be allowed to walk to 
a flat, hard couch or table covered with a rug. The position of the limb and 
the child's gait should be carefully watched. Then, with the child lying 
straight and flat upon its back, any abduction of the limb should be looked 
for, an imaginary test line passing downwards from the middle of the 
sternum through the umbilicus and pubes being taken as the guide. The 
length of the two limbs, taking into account the pelvic tilting, is now to be 
compared. The next point is to notice whether the affected limb is put 
down flat upon the table — i.e. whether the thigh and knee are flexed or the 
back arched (lordosis) — also whether there is any wasting of the limb. 
The surgeon should then take the sound limb gently in the hand and fully 
flex it, looking for any movement of the pelvis ; as soon as the full degree of 
flexion has been ascertained the affected limb should be very gently raised 
and its range of mobility compared with that of the sound side, a finger 
being kept on the anterior superior spine of the ilium to feel for any tilting 



Prognosis jo i 

of the pelvis. Should there be any lordosis due to fixed flexion of the hip, 
this will disappear as the limb is raised and be increased by extending the 
leg. The finger, or better the thumb, should then be gently pressed into 
each iliac fossa to feel for swelling there, due to enlarged glands or the 
presence of an abscess ; fulness below Poupart's ligament should also be 
looked for. If no restriction of movement has been found, abduction, 
adduction, and rotation should be tested and the two sides compared. 

The child should next turn over and lie on its face — it is generally better 
to allow it to turn in its own way ; the shape of the buttock, the thickness 
of the trochanters, the gluteal fold, and rima natium are now inspected and 
the range of extension further investigated. The spine and sacro-iliac joints 
should be examined at this stage, swelling of the knee joint and thickening 
of the shaft of the femur having been previously searched for. If there is 
still a doubt, a finger should be passed into the rectum, and the inner wall 
of the pelvis examined for thickening, or abscess, or enlarged glands ; for 
this proceeding it is often necessary to give an anaesthetic. Where disease 
begins in the acetabulum, but' has not yet reached the cavity of the joint, pain 
and slight lameness may be the only obvious symptoms. Mobility of the 
joint may be almost perfect. In such cases the presence of thickening felt 
per rectum as well as by deep pressure in the iliac fossa is all-important as a 
means of diagnosis. 

No one symptom alone is sufficient for a diagnosis in early stages, but 
limitation of movement to some extent, and trochanteric thickening, are 
perhaps the two most valuable signs of joint disease. 

We would here deprecate the use of any of the means of diagnosis w T hich 
necessitate giving pain to the patient. The presence of disease is re- 
cognisable by the painless mode of examination in all cases where it can be 
made out at all. In all cases examination for hip disease should be made 
with the child completely stripped, and lying on a flat hard couch or 
table. 

Prognosis. — As regards the prognosis and the results of affections of the 
hip joint when treated by means other than operation, it is necessary to dis- 
tinguish clearly between the two morbid conditions of acute synovitis and 
osteomyelitis, acute or chronic : the former recover perfectly with freely 
movable joints under proper treatment, and show no after ill effects, though 
the treatment required is usually longer than that for other joints. On the 
other hand, cases of true hip disease; unless effectually treated in the early 
stage, very rarely recover without more or less destruction of the upper 
epiphysis of the femur, usually accompanied by abscess, and always result in 
shortening with more or less deformity, and a very large majority die before 
reaching adult life. 

Even when tuberculous disease of the hip seems to have subsided, 
relapses are exceedingly common after some slight injury or intercurrent 
illness. It is important, however, to distinguish between relapses due to a 
fresh lighting up of disease and the presence of an abscess the result of irri- 
tation by some quiescent local product of former inflammation — the residual 
abscess of Paget. 

As to the usefulness of the limb after recovery from hip disease without 
operation, more or less shortening is to be expected in all cases, either as a 



702 Hip Disease 

result of malposition, retraction of the femur upon the dorsum ilii, actual 
destruction of bone, or arrest of growth of the femur ; the last is the least 
important factor, since increase of length in the femur takes place almost 
entirely at the lower end, and what shortening there is is due rather to 
general arrest of growth of the limb than to destruction of the upper growing 
line. 

In private practice, where hip disease is seen early and treated more 
effectually than it can be in hospital practice, the prospect of recovery is 
much better, though even here a perfect result is rare ; it will, however, be 
obtained under exceptionally favourable conditions. A movable joint may 
be obtained where the disease comes under treatment in its early stage, or 
even after destruction of the joint there may be a certain amount of mobility, 
though this is less frequent than it is after excision. 

In fatal cases of hip disease death is generally due to tuberculosis or 
exhaustion, with hectic or lardaceous disease ; sometimes an intercurrent 
exanthem proves fatal. Hence it is seen the prognosis depends very 
largely upon whether early and efficient treatment, of which that by 
Thomas's splint is undoubtedly the best, can be obtained. The cases least 
likely to do well without operation are those in which there is a great amount 
of thickening, and those in which, in spite of fixation, pain continues, while 



Fig. 161. — Bryant's Splint. We have had sliding pieces made to fill up the interruptions 
when required ; this is seen in the figure. 

under any circumstances the prognosis is bad if there is extensive pelvic 
caries (not necrosis). 

Treatment. — First, the ideal treatment consists in seeing the case early, 
keeping the child in bed until by simple extension or a Bryant's splint the 
limb is straightened ; then a Thomas's splint should be applied, 1 and the 
child allowed to get up and about, out of doors, by the seaside. Good 
food, cod-liver oil and iron, with occasional administrations of rhubarb and 
soda if any dyspeptic troubles appear, comprise the rest of the management. 
Two years should be the time given for rigid treatment ; after this the 
splint may be gradually laid aside, and the child allowed to go about with 
a patten and crutches for a few weeks ; if there is still no sign of disease, 
walking upon the affected limb may be gradually permitted. During the 
time of treatment the greatest care must be taken not to allow the foot of 
the affected side to touch the ground, and to avoid all falls or strains of the 
joint. 

American surgeons use to a great extent ' traction splints ' of various 
forms, in which, while the patient gets about more or less, extension is kept 

1 Or the limb may be straightened by means of the Thomas's splint. 



Treatment by Extension 



703 



up. 1 The weak point in most of these appliances is that the joint is not 
fixed, though fixtion of the joint is now much more generally recognised 
as essential than it was some years ago. 

In hospital practice the nearest approach to the above lines of treatment 
should of course be carried out, but if there is progressive disease, and the 
management is unsatisfactory, the question of operation must be considered. 
If sinuses exist with receding disease, diminishing discharge, and puckering in 
of cicatrices, or if with an abscess the mischiet is quite quiescent or receding, 
non-operative treatment should be adopted for a time, if it can be thoroughly 
carried out ; if not, or if no progress is made in a few weeks, the diseased 
part should be removed. 

In applying extension by weight it should be made an invariable rule to 
make traction from the condyles of the femur, and not from below the 
knee. A case is on record in which prolonged extension applied below the 
knee resulted in separation of the upper epiphysis of the tibia. It is also 




Fig. 162. — Shows extension by a weight applied above the knee, with a long splint on the 
sound side. Also the simple plan of keeping the child from sitting up by means of the board 
running behind the shoulders and fastened to the side of the bed. The shoulders are 
fastened to this board, and the arms are left free below the elbow. The bed on which the 
child lies is somewhat too soft. 

objectionable in that it throws strain upon the knee joint, and is more apt to 
slip off. The strapping should always, if possible, be applied for some hours 
before the weight is attached, in order that the plaster may get set, and not 
be dragged off by the weight. The strapping (of which Leslie's brown 
holland is the best) should be kept from the skin by a strip of lint or flannel 
bandage, or part of a stocking, to protect the sharp edge of the tibia and the 
prominences of the joint from pressure (fig. J62). 

We have found that too great extension may be a cause of painful 
spasms, and it is well to bear this in mind, that too great extending force and 
too little are alike inefficient. In cases where treatment without operation 
is carried out, as for instance where adhesions, the result of old inflam- 
mation, exist, or muscular contracture has taken place, the deformity may 
be remedied in many instances by the ordinary extension apparatus, by a 

1 For a good account of these splints we must refer to Dr. Lovett's work on Disease of 
the Hip, 1892. 



704 Hip Disease 

weight, or by Bryant's splint. In other cases, where simple extension is 
inefficient, or too tedious, it may be necessary to forcibly straighten the 
limb under chloroform, and then fix it by splints in its new position. The 
advisability of forcible straightening is a somewhat disputed point and is 
not in all cases free from risk, not only of laceration of important structures, 
but of setting up fresh inflammation in the joint or what remains of it. 

Mr. Howard Marsh, 1 and in 1836 Sir Benjamin Brodie, advised that 
the extension should be made in the axis of the misplaced limb, and that 
the direction should be altered as the limb regains its normal position. We 
do not think this a matter of great importance. If it is desired to carry out 
this plan, probably Hodgen's splint for fracture of the thigh would be the 
most efficient apparatus. 

It is sometimes a matter of difficulty to remedy the malposition of the 
limb in cases of fixation in combined flexion and adduction or abduction. 
Here, where possible, gradual reduction by a Bryant's splint is the best 
treatment (fig. 161) ; failing this — and it cannot be always used— a,long splint 
on one side, with a weight to the mal-placed side, should be tried (fig. 162) ; 
and, failing this, careful straightening under chloroform. Where there is 
much abduction Volkmann applies a weight to each leg, the heavier one 
being attached to the sound side. (A. H. Tubby.) These methods are, we 
think, better than remedying the deformity by weights applied laterally. In 
more acute cases, where the deformity is mainly due to spasm, gradual 
extension is best, but by some means the limb must be got as quickly as 
possible into good position. 

Thomas's apparatus is a very valuable appliance, and is undoubtedly the 
best splint we have for patients able to be up (figs. 163 and 164). The splint 
requires careful attention to detail, both in fitting it and in management ; it 
is of use, first, in the early stages of disease, where it is possible to give the 
child the chance of long-continued and perfect rest, with general hygienic 
measures ; and, secondly, after excision, to keep the limb quiet for a time 
until the parts are sufficiently consolidated to allow of movement being- 
begun. We have habitually used it for many years. 

The question of when to excise a hip joint is no doubt a difficult one, but 
the conclusion we have come to is this. Treatment, short of excision, when 
once suppuration occurs, is, if the disease is progressi?ig, useful only as a 
palliative. Our opinion, bearing in mind Mr. Holmes's valuable remarks 
on the social circumstances of these patients, is that where there is an 
abscess outside the joint, or, without this, great trochanteric thickening, with 
much pain that does not yield to treatment by rest and efficient cleaning out 
of the ' abscess,' excision ought to be performed. In private practice cases 
are usually seen in the first or early second stage, and it is possible to 
ensure that the Thomas's splint shall be kept on and no strain thrown upon 
the joint : hence recovery without operation is the rule. While fully aware 
that abscesses disappear and tuberculous lesions cicatrise under favourable 
circumstances, we think that in the case of the hip delay is unwise among 
the hospital class, with whom it is as yet impossible to deal on the same 
lines as with the well-to-do. In almost every instance we have found much 
more extensive disease than might be expected from the external evidence, 
1 Brit. Med. Jour. July 1876. 



Excision of the Hip 



70S 



unless the pathology of the affection is borne in mind, and we believe that, 
once this chronic osteomyelitis is fully established, excision in a large pro- 
portion of hospital cases is the proper course. Nature, of course, in many 
cases will, unaided, get rid of the dead bone by slow and tedious processes, 
but the number of children who can survive the process of elimination is 
very small, while the mortality after early excision is not great, and the 
failures are mainly in those instances where the operation has been put off 
till too late. Where actual necrosis, or caries of the head of the femur, with 
destruction of bone and cartilage, and often sequestra of varying size in the 
acetabulum, or at least caries of it, is known to exist, we think few advocates 
of non-operative treatment will be found. It is then, as Mr. Bryant points 





Fig. 164. — Thomas's Hip Splint adjusted 
for a case with no deformity. 



Fig. 163. — Thomas s Hip Splint, applied. Slightly 
altered from Mr. Thomas's work on the ' Hip, 
Knee, and Ankle.' 

out, to be looked upon rather as an ordinary operation for necrosed bone 
than anything more formidable ; and that this is the state of the joint even 
in cases often spoken of as those of early disease is the fact upon which we 
should like to lay stress. 

While we advise excision in all cases in which the disease progresses in spite 
of adequate treatment, we have come to the belief that modern methods of 
abscess treatment and efficient use of splints have enabled us to reduce the 
number of excisions. Thus in seven years, 1886-93, 83 excisions were per- 
formed, while in five years, 1894- 1898, 31 excisions of the hip were done 
at the Children's Hospital by the writer. 

It is necessary of course to distinguish sharply between abscess the 

z z 



yo6 Hip Disease 

result of progressive disease and residual abscess; it is in the former that 
the question of excision arises. Where the disease is quiescent, abscesses 
may well be dealt with by the method already described, of thorough 

cleaning" out and closure after injection of iodoform emulsion. We are not 
disposed to think that mere injection of iodoform into tuberculous joints with- 
out removal of the original focus of disease will be successful to any great 
extent. It is undoubtedly useful in some cases to deal with the abscess 
first, and, when that has healed, to remove the diseased bone by a second 
operation under more favourable conditions. The operation of excision is 
discredited because it is put off until disease is so far advanced that no mode 
of treatment can have more than a small proportion of good results ; while 
timely excision cuts short the disease, saves pain, lessens the time of treat- 
ment, and gives a better limb. 

We have in this edition considerably modified our statements in former 
editions as to excision. We do not perform excision now as frequently as we 
did in former years. Cases of hip disease are brought, we think, earlier than 
they formerly were, the treatment of them has been more efficient before 
they are brought to hospital, and the treatment in hospital is also better. 
Probably a not less important factor in the reduction of excision operations 
is the great advance in the treatment of ' abscess.' The modern method ot 
thoroughly cleaning out the cavity with removal of all detritus and closing 
it again completely by suture reduces a certain number of these cases to a 
condition nearly corresponding to early disease. Hence we have reduced, 
and hope still further to reduce, the number of cases of disease in all joints 
which require radical operations. While thus recording with satisfaction 
our belief in the important advance made of late years in the treatment of 
joint disease, we still urge the importance of excision in every case in which 
in spite of good treatment the disease is progressive, and not only this, but 
excision before the disease has gone too far. If we leave it as a last resort 
we shall diminish the number of excisions, but increase the roll of amputa- 
tions and deaths. Excision must of course always be necessary where pelvic 
or extensive femoral necrosis exists. 

Modes of Excision. — Various incisions for removal of the upper end of 
the femur have been advocated. Of these the incision over the middle of 
the trochanter and slightly concave forward is the one we usually adopt. 
We see no advantage in most of the others over the one extending downwards 
for about three inches, more or less according to age and the extent of the 
disease, along the middle of the trochanter. Where, however, it is proposed 
to remove a large part of the pelvic wall, a flap operation is desirable, and 
we have recently frequently used it ; the flap incision has the advantage of 
freely exposing the diseased area and allowing thorough cleaning of the soft 
parts, and by chiselling off and turning up the trochanter with its muscles 
attached the power to move the limb subsequently is likely to be greater. 

Next, if a flap is not made, the soft parts should be divided vertically 
above the trochanter and the capsule opened freely, if this has not been 
done by the first incision. The joint should then be explored with the 
finger. 

The next step is to separate the soft tissues from the bone on the inner 
side, stripping back the periosteum as far as it exists as such. The finger 



Excision of the Hip 707 

should then be used to pass round the bone and feel that the upper end 
is free ; next, still using the finger as a guard at the inner side of the bone, 
the femur should be sawn through just below the trochanteric margin with a 
keyhole- or finger-saw. Some part of the trochanteric epiphysis is usually 
left behind. The upper extremity of the bone is then readily prised out with 
the finger or raspatory. The acetabulum should be then examined and any 
sequestra removed. If there is a large carious surface, it may be gouged or 
scraped with a Volkmann's spocn or left alone. It is well to remove any 
rough or semi-necrosed bone, but we doubt the possibility of being able to 
remove all the disease without greatly adding to the severity of the operation 
where there is extensive inflammation without necrosis, nor is such treatment 
desirable. 

The upper end of the femur should be examined to see if the whole 
disease has been removed ; if not, a further section should be made, and 
this may be carried a considerable distance down the shaft ; six inches have 
been removed with a good result, and but little shortening, by an American 
surgeon. 

Here it is well to point out the danger of the practice of thrusting the 
head of the femur forcibly out of the wound before sawing it through, instead 
of dividing it in situ. Several cases of fracture of the shaft of the atrophied 
fatty bone have occurred. An additional objection to this practice is the 
ease with which the periosteum may be thus stripped off the inner aspect of 
the shaft, and so necrosis may occur. 

The operation is much more easily and safely done in the way described, 
and involves less violence to and less division of the soft parts. The finger 
is quite as good a guide as the eye to the condition of the bone. 

Usually no vessels require ligatures, though there is sometimes free 
oozing of blood. If the wound can be made aseptic, it should be carefully 
cleaned and closed by sutures after injection of iodoform emulsion ; if the 
case is one with old-standing sinuses, we prefer to leave it quite open, and in 
that case a large drainage tube should be passed deep into the cavity of the 
joint. Any sinuses or abscess cavities should then be thoroughly scraped 
out and well cleaned before applying the dressing. It will often be found 
that a distinct membranous layer of lymph lines the cavity of the articulation, 
but there is rarely anything like the thickness of granulation tissue so often 
seen in the knee and other joints. It is well to remove any masses of pulpy 
granulations should they exist, but anything like the elaborate dissection 
required in erasion of the knee is impracticable. 

In many cases we make our section through the neck of the femur, but 
in some cases the head of the femur is so far destroyed that it would be 
impossible to do less than take away the trochanter, while the trochanter if 
left in cases that require drainage tends to block up the orifice of the wound 
and prevents the free escape of discharge and debris of bone, and thus 
interferes with one of the main objects of the operation. This argument 
does not, of course, apply where it is possible to close the wound entirely. 
The Clinical Society's Committee advised that the trochanter should be left 
unless diseased, or unless there is extensive pelvic disease, and where the 
flap operation is employed it must be left. 

Where intrapelvic abscess exists the acetabulum should be perforated. 

z z 2 



708 Hip Disease 

Examination per rectum enables the diagnosis to be made if this condition 
is suspected. 

The most convenient form of dressing afterwards is a thick pad of wood- 
wool wadding, over a thin layer of wet gauze. Iodoform should be freely 
dusted into the wound before applying the dressings, or iodoform emulsion 
injected. 

Messrs. Barker and Pollard, in December 1888, brought before the Medical 
and Chirurgical Society of London a method of managing the operation of 
excision of the hip. The method consists in clearing away all disease of the 
soft parts by scraping or excision ; scraping out abscess cavities, and by 
means of thorough and careful asepticism getting the wound clean. The 
novelty is in their mode of carefully drying out the wound and closing it en- 
tirely after removal of all tuberculous material as far as possible, so that 
primary union is obtained. Messrs. Barker and Pollard showed cases in 
which this result had been obtained, and we have since then followed their 
plan in its main features with success. There is no doubt this is a most 
valuable improvement ; it is, of course, applicable to cases of early excision 
chiefly, or only, and experience shows that even so there is some danger of 
relapse (p. 711). For further details we must refer to the ' Medico-Chir. 
Transactions,' 1888 ; but we may reprint here Mr. Pollard's abstract of the 
essentials of the method : 

1. The whole of the tubercular growth must be removed. 

2. Perfect asepsis must be assured. 

3. Bleeding must be checked and the wound made as dry as possible. 

4. Oozing must be checked by the even, elastic support of a wool dressing 
and a moderately tight bandage. 

5. Absolute rest of the part must be maintained during the process of 
healing. 

Following Mr. Howse, we prefer to have the extension put on before the 
operation, so that the weights, or, better, Bryant's splint, can be applied at 
once before the patient is put to bed. The shock of the operation is some- 
times somewhat severe, but usually soon passes off under the use of opium 
and stimulants. Rarely, however, much more severe and prolonged shock 
occurs. 

The subsequent management of the case requires some special remarks. 
It is exceedingly difficult to keep the wound aseptic in cases where sinuses 
have previously existed or where there is widespread suppuration. It is, 
however, a great gain if the wounds can be kept sweet even for a time, and 
with present methods primary union after excision may be expected in a large 
proportion of cases. Vide Note, p, 712. 

The after-treatment of cases of excision simply consists in dressing and 
in keeping the limb quiet and in good position. This may be done by various 
means, of which the best are simple extension by a weight (the weight may 
usually be reckoned at one pound for each year of the child's age from two to 
six ; six pounds is generally enough up to twelve years of age, after which 
more may be added), with or without a long splint on the opposite side, and 
a Bryant's double splint, which has many advantages in securing ' parallelism 
of the two limbs,' and in the ease and comfort with which the patient can be 
moved. It is an invaluable apparatus, and we now almost invariably 
use it. 



Excision of the Hip 



709 



The sooner excision cases are got up and about the better ; some cases 
may leave their beds in three weeks ; others, of course, are much longer in 
getting up, the difference depending mainly upon the state of the disease at 
the time of operation. 

The period of convalescence after excision varies from the time mentioned 
to two years, while in some cases sinuses may remain open much longer if 
pelvic disease exists. We keep our patients usually in a Thomas's splint for 
from at least three to six months after excision ; after this the child, if 
old enough, should get about with a patten and crutches, allowing the limb 
to swing, and only after a year or more should he be allowed to gradually 
bear weight upon the leg. If, however, excision 
is done early, the limb is fit for walking sooner, 
sometimes in five or six months. If the affected 
leg is allowed to touch the ground too soon, it 
becomes pushed up upon the dorsum ilii, and 
much shortening results. On the other hand, 
if the limb is fixed too long, it becomes stiff. 
A very large proportion of cases of excision in 
the later stages of the disease remain with 
sinuses, but often these produce no ill result 
except the trouble of dressing them ; a certain 
number may be got to close by scraping, cautery, 
&c. ; others are very intractable. In a certain 
number of cases the wound re-opens after having 
healed ; this is undoubtedly common, but is due 
to over-use, neglect, or violence, and with ordi- 
nary care and frequently repeated scrapings with 
closure of the wound after excision of tuberculous 
tracks and edges of skin, the wounds usually 
again close. 

It is interesting and important to note that 
in measuring the amount of shortening after 
excision the real shortening — as measured from 
the upper end of the femur to the malleolus on 
each side — is often trifling, and sometimes 
there is none, while the practical shortening as 
measured from the pelvis to the malleolus is 
considerable. Though some shortening will 

necessarily result, any large amount is due to weight being borne upon the 
limb prematurely. It has already been pointed out that growth in length of the 
femur takes place almost entirely at its lower epiphysial line ; hence the loss 
of length or true shortening is only the distance from the line of section to 
the top of the head, coupled with such arrest of growth as may result from 
impaired nutrition, this last being, of course, a very inconstant quantity. 
Oilier estimates that during the first four years of life growth takes place about 
equally at each end of the femur ; after that time the lower end grows more 
rapidly. 

The primary objects of the operation of excision of the hip are to save 
life and relieve pain ; the next most important question is that of the useful- 




Fig. 165. — From a photograph 
showing a good average result 
after excision, when the leg has 
been walked upon, and the 
stump of the femur is thrust 
up upon the dorsum ilii. 



yio Hip Disease 

ness of the limb and of the condition of the "joint 5 after the operation. One 
of two results must occur after excision : either a freely movable limb, or one 
with varying degrees of stiffness, from some mobility to bony ankylosis. 
Bony ankylosis after excision is very rare. Close fibrous union, so that but 
little mobility remains, is very common ; movement through from 30 to 50° 
is perhaps the commonest result, and a smaller number have complete 
mobility. 

It is not possible to estimate in figures the results to be expected from 
excision ; for details we must refer to the monograph mentioned at the 
beginning of the chapter. 

Whether, then, we consider the pathology of the disease, the actual local 
condition, the relief of pain, the preservation of life, the duration of illness, 
the condition of the limb and its usefulness, or the dangers of secondary 
disease, on every ground, in our opinion, excision is the best course under 
the circumstances and with the limitations already stated. 

Chronic Synovitis of Adolescents. — Occasionally in young rapidly 
growing lads or girls, usually from 12 to 17 years, a chronic synovitis of 
the hip occurs often apparently, due to strain or long standing. It causes 
pain, lameness, and some stiffness of the joint with effusion, but little or no 
swelling around the trochanter, though this may appear prominent. The 
softening of the ligaments by the inflammation may lead to complete or partial 
dislocation of the head of the femur. We believe we have seen this condition 
associated with coxa vara. The treatment is prolonged rest, and the pro- 
spect of recovery is good, though some stiffness may remain for a long time. 

Conclusions. — 1. The hip joint in childhood is commonly subject to two 
affections : (a) simple synovitis ; {b) tubercular disease. 

2. Simple synovitis is usually traumatic, very rarely suppurates, is amen- 
able to ordinary treatment, and as a rule leaves behind no bad results. 

3. Tubercular disease, or common, 'hip disease,' affects primarily the 
upper end of the femur, or occasionally the acetabulum, and produces necrosis 
or extensive caries. 

4. In the earlier stages of hip disease, before caseation of bone or suppura- 
tion has taken place, proper treatment will, in a fair proportion of cases, 
result in recovery with a nearly perfect limb. 

5. As soon as suppuration occurs, it is certain that recovery will not 
take place without destruction of the upper epiphysis of the femur more or 
less completely. 

6. The process of removal of the diseased bone without operation is so 
slow, so exhausting, and so uncertain that it should be reserved for those 
cases where time and p care can be fully devoted to it. 

7. A case of hip disease, seen before suppuration has occurred, is best 
treated by the use of a Thomas's splint with or without previous straightening 
by extension. 

8. Excision of the hip cuts short the disease, relieves pain, and gives a 
better limb than the average result obtained without operation in cases of 
equal severity. 

9. Excision should be looked upon as an ordinary operation for necrosis, 
and the operation itself is not necessarily attended by a higher mortality than 
sequestrotomy elsewhere. 



Summary 7 1 1 

10. Excision in old pelvic disease, or where the health is broken down, 
or the patient is over fifteen years of age, should usually be rejected in favour 
of amputation. 

1 1. The presence of a sinus after operation, unless there is much discharge 
or evidence of extensive pelvic disease, does not imply failure of the operation. 

12. The presence of an abscess after a long period of quiescence (resi- 
dual abscess), without other evidence of relapse, is not to be looked upon as 
of serious import. 

Amputation. — The question of amputation at the hip joint for disease is 
one of the highest importance. We must consider not only the unavoidable 
mortality and crippling caused by the disease, but also the interference with 
pleasure and education entailed by long confinement indoors. Where there 
is no reasonable prospect of recovery with a useful limb, amputation must 
not be too summarily set aside. 

There is little doubt that, in cases of extensive disease where the femur 
is necrosed for a long distance and the powers of the patient are inadequate 
to repair it, in cases where descending osteomyelitis occurs, and in cases 
where profuse discharge and amyloid disease come on, amputation should 
be performed. 

In cases of more advanced amyloid disease, unless the powers of the 
child are so enfeebled that the operation will prove fatal by shock, it ought 
also undoubtedly to be done. 

In another class of cases the question is more difficult. Where there is 
disease of the pelvis, is amputation contra-indicated if other conditions re- 
quire it ? We should answer yes, if the pelvic disease extends so widely 
that there is no hope of removing it all, and the condition is one of caries and 
not necrosis. Where there is caries limited to the neighbourhood of the 
acetabulum, where there is necrosis, or where there is reason to think that 
the disease in the limb is preventing repair in the pelvis, amputation should 
be performed. 

As to the question of saving life, amputation at the hip performed with 
due precautions as to haemorrhage and shock, and special care during the 
first twenty-four hours, is by no means a fatal operation in children. 

We have amputated in some fifteen cases in children. In nearly all 
excision had been previously performed. All of these recovered well from 
the operation except one who died from haemorrhage. 

The best plan is the oval incision of Furneaux Jordan ; the excision 
wound should be utilised, and the line of section brought as far as possible 
from the anus and vulva. 

Neither the various methods of operation nor the best means of con- 
trolling bleeding are questions suited for discussion here. Elevating the 
limb before operation, and digital pressure with the help of an elastic tour- 
niquet in the early stages of the operation, are as efficient means of control- 
ling the haemorrhage as any ; in several cases we have ligatured the femoral 
or external iliac as a preliminary, and think well of this plan. 

If possible, it is, as pointed out by Mr. Shuter, well to preserve as much 
periosteum as possible, and it will be found that after excision the bone 
usually very readily separates from the periosteal sheath ; a longer, firmer, 
and more or less mobile stump may be thus obtained. 



712 Hip Disease 

Double Hip Disease is not a very rare condition, and we have more than 
once had cases in which the second joint has become diseased while the 
child was lying in bed for the treatment of the first joint. The management 
of these cases is that of the common condition, except that a double Thomas's 
splint is of course required. Double excision is occasionally called for, and 
we have had good results from it ; in one case the child remains sound and 
well, and is able to walk without support. 

Scissor-leg-g-ed Deformity after Hip Disease. — Mr. Lucas, Dr. Tyson 
of Folkestone, and others have recorded cases where, as a result of double 
hip disease, a peculiar 'cross-legged' or ' scissor-legged deformity 5 occurs ; 
both legs are adducted, the one in front of the other, and progression takes 
place entirely by movement at the knee joint. It is easy to understand the 
condition by simply walking with the knees crossed over one another. It 
occurs, according to Mr. Lucas, in cases w T here disease has taken place first 
in one joint, resulting in adduction, and then subsequently in the other joint. 
Other deformities may result from the same condition. 

Adduction after Subsidence of Hip Disease. — This is unfortunately a 
common and most troublesome cause of crippling after active disease has 
subsided. It results from inadequate treatment while the disease is active, 
or premature removal of splints ; also very often from the bad habit these 
patients acquire of resting the foot of the affected limb upon the dorsum of 
the other foot. The deformity may in some cases be remedied by extension 
either direct or at right angles, but in severe and rigid cases it may be 
necessary to osteotomise the upper end of the femur with or without division 
of the adductors before the limb can be straightened. 

Note. — Our former Senior Resident, Dr. Carruthers, now of Congleton, has kindly 
gone over our records of excision of the hip from 1886 to 1893 performed by the writer. 
He reports that 83 operations have been done, of which in 31 instances the wound was 
sutured without drainage. Of these 22 healed at once, i.e. by primary union throughout, 
or with the exception of small superficial areas ; 9 cases failed to unite at once, and 5 of 
the 22 which united broke down again after varying periods. These figures must be taken 
as approximate only, inasmuch as wounds may have re-opened shortly after discharge, and 
in one or two cases of the 83 the result is doubtful. 



713 



CHAPTER XXXII 

SPINAL DISEASE 

"Caries of the Spine, Angular Curvature, and Pott's Disease, are 

terms which, as commonly used, include conditions of very varying severity 
affecting several different structures. This is so, since the spinal column is 
in each segment provided with several different articulations, and any of 
these, as well as the bone itself, may become the seat of disease. Thus the 
mischief may begin at the junction of a vertebral body and intervertebral disc, 
at the junction of a vertebral body with its epiphysis, in the centre of a body, 
or on its anterior, posterior, or lateral surfaces ; or, again, the articular pro- 
cesses, or their joints, the transverse and spinous processes, may any of 
them be separately diseased. Again, the mode of connection between the 
skull and atlas, the atlas and axis, and the sacral joints implies necessarily 
varying conditions from those found in disease of the rest of the column. 

Obviously the names given to disease of the spine are not equally 
applicable to all these affections ; disease of a spinous or an articular pro- 
cess does not give rise to angular curvature. It is, however, quite the ex- 
ception to find in children disease of the spine affecting any part except the 
bodies and intervertebral discs ; we can only call to mind two cases of disease 
of a spinous process alone, one of which was the following : 

Case. — Necrosis of the Cervical Spinous Processes. — Edward H. , age 4 years 5 months ; 
admitted July 21, 1882. Six weeks ago a hard lump was noticed at the back of the neck, 
he having, a fortnight before, fallen on the back of his head ; the swelling had gradually 
increased, but he had had neither pain nor tenderness. On admission he was well nou- 
rished ; there was a large fluctuating swelling in the middle of the back of the neck ; it was 
opened antiseptically, and about dr. iij of healthy pus escaped ; the tips of one or more 
spines were bare ; the dressing slipped the next day ; the abscess continued to discharge, 
and he was sent out on August 25 with a jurymast on and a still unhealed sinus. In January 
1883, at Out Patients', he was nearly well : the movements of the neck were perfect and the 
thickening nearly gone, but there was still a small sinus. Subsequently a sequestrum 
consisting of the spinous process was removed, and he quite recovered {vide Chapter on 
Diseases of the Bones). 

We have never verified a case of disease of a joint between the articular 
processes, and disease of the transverse processes is rare. The atlanto-axial 
and occipito-atlantoid joints are also very rarely affected in children in com- 
parison with caries of the bodies. 

The ordinary form of caries of the spine affecting the bodies or interverte- 
bral discs or both structures is met with in all parts of the spinal column 
from the axis to the sacrum. In a hundred cases taken at random from our 
Out-Patient papers we found eighteen cases of cervical disease, forty-one 
cases where the cervico-dorsal, upper, or mid-dorsal regions were involved, 



7H 



Spinal Disease 



thirty-three instances of lower dorsal or dorso-lumbar disease, six of lumbar 
caries, and two of disease of the sacrum. R. W. Parker, as quoted by 
Erichsen, gives the following figures : Cervical nine, dorsal eighty-two, 
dorso-lumbar twenty-one, lumbar or lumbo-sacral thirty-seven, out of 149 
cases. These figures are of some importance, for, in the first place, no 
attempt at removal of diseased bone can be made in the dorsal region, and 
only exceptionally in the cervical part of the spine, while the treatment of 
the disease by apparatus becomes more troublesome as we ascend from the 
mid-dorsal region. Pus is more likely to point externally as lumbar or 

psoas abscess when the lower dorsal 
^sS§|j|; or lumbar vertebra; are attacked, 

though it is not rare for dorsal 
abscesses to track down the spine. 
Cervical abscesses point in the pha- 
rynx or side of the neck. Lastly, 
occasionally two foci of disease exist, 
as in fig. 166. 

Pathology.— It is probable that 
caries of the spine begins nearly 
always in the body of the vertebra, 
and not in the intervertebral disc 
itself ; but it is difficult to be sure of 
the relative frequency of these sites, 
for the mischief soon spreads beyond 
the limits of a vertebra in most in- 
stances. Erichsen considers the epi- 
physial lines, the front of the bodies, 
and the centre of the bodies to be in 
this order the most frequent primary 
seats of disease. Wilks and Moxon 
apparently incline to the belief that 
the bones are the primary seat of 
' scrofulous ' disease in children, while 
disease beginning in the discs is a 
separate type of lesion — at all events 
in some cases the result "simply of 
injury ; probably the seat of disease 
varies. In most cases the lesion is 
an ordinary tuberculous disease of 
bone, rarefying ostitis being found in some parts, while in others caries 
necrotica or more extensive necrosis exists. Although a large number of 
patients, the subject of caries of the spine, never develop external abscesses, 
it by no means follows that no suppuration takes place ; large collections of 
pus may form beneath the anterior common ligament in the dorsal region 
without ever discharging, and may, like abscesses elsewhere, dry up and 
remain as cheesy or calcareous masses. More rarely the abscess may empty 
itself into the lung or intestine ; the latter result we have seen in a case of 
lumbar caries and in sacral disease, and it is probably more common than is 
supposed, the pus in the motions being overlooked or put down to enteritis. 




Fig. 166. 



-Caries of the Spine, showing 
foci of disease. 



A bscess — Deformity 7 1 5 

In other instances caries of the spine, like caries elsewhere, may be through- 
out unattended with any pus formation (caries sicca). 

There is often a discharge of small sequestra from spinal abscesses, and 
sometimes fair-sized pieces of dead bone come away or are extracted, but 
this is not common ; as in the well-known instances of the odontoid process 
coming away entire through the pharynx. 

Pus from a lesion in one part of the spine may track downwards and give 
rise to a second focus of disease lower down, but sometimes, as in fig. 166, 
the two foci are quite independent and isolated from each other ; in the 
case from which the figure was taken the lower patch of disease developed 
first. 

In some instances disease may begin as a simple non-tuberculous 
inflammation, the result of injury as already mentioned ; this is not, however, 
common in children in our experience, since in them the disease usually 
runs the course of tuberculous lesions generally. Cases of spinal curvature, 
due to the lesions of congenital syphilis, are also described. 

Abscess. — Pus in connection with spinal caries usually burrows along 
certain definite lines determined by muscular and fascial barriers ; thus in the 
neck, abscesses are either prevertebral, bulging forwards into the pharynx, 
as in atlanto-axial disease, or point at the side in the posterior triangle, just 
behind the sterno-mastoid, sometimes on both sides. 

In the lower cervical and upper dorsal regions the abscesses, if they exist, 
rarely point externally, but if they do so either track down the spine and 
appear as lumbar or psoas abscesses, or perforate an intercostal or intertrans- 
verse space and appear in the back. Abscess in upper dorsal caries com- 
paratively rarely points externally. Dorsal and lumbar caries commonly 
gives rise to psoas abscess, the pus getting into the sheath of the muscle at 
its upper attachment and burrowing down within it, often entirely destroying 
the muscle itself ; it then may either pass outwards into the iliac fossa, 
beneath the iliac fascia, and form a swelling there (iliac abscess), or, travelling 
on beneath Poupart's ligament, bulge in the thigh on the outer side of the 
femoral sheath as a psoas abscess. Often, however, though forming a col- 
lection in front, the matter does not point there, but, passing on behind the 
vessels towards the lesser trochanter, appears at the back of the thigh as a 
gluteal abscess. In other instances the pus finds its way round the edge of 
the quadratus lumborum and through the transversalis aponeurosis, perhaps 
in the course of a branch of a lumbar artery, and points in the back (lumbar 
abscess). Again, the pus may gravitate backwards into the pelvis and escape 
through the sciatic notch, appearing as another form of gluteal abscess. We 
have seen an abscess bulging at both sciatic foramina, so that fluctuation 
could be felt across the cavity of the pelvis. Less often the abscess descends 
over the iliac crest on its outer aspect, or burrows forwards between the 
layers of the abdominal wall. Once it has reached the thigh, matter may 
track down it for an indefinite distance. 

Deformity. — In most cases caries of the spine sooner or later gives rise 
to angular deformity (kyphosis). This is, of course, due to destruction of 
the bodies of one or more vertebrae, and consequent collapse of the column ; 
or possibly, to a certain extent, is caused by muscular contraction drawing 
together the adjacent bodies, the spines being thereby made to project 



yi6 Spinal Disease 

posteriorly. The amount of deformity in such cases varies from a mere faint 
prominence of one vertebral spine, only to be recognised by careful observa- 
tion, to a great prominent ' knuckle' involving six or eight vertebrae. When 
the disease is in the dorsal region, the falling together of the vertebral bodies 
produces a corresponding chest deformity ; the ribs are brought close 
together, the shoulders are raised, and the head looks sunken between them, 
the antero-posterior diameter of the chest being increased at the expense of 
the vertical. 

In the cervical region the deformity is usually much less marked ; some- 
times, however, there is a prominent angular curvature, and the head is 
drooped forwards with the chin upon the sternum ; or the head and upper 
cervical vertebrae are poked forwards with a projection backwards at the 
root of the neck. 

It must be remembered, however, that these deformities occur only in 
an advanced stage of destruction, and only when the whole breadth of a 
vertebra is eaten away ; thus, disease of one side or the posterior part of a 
body may exist without any angular deformity, and in some instances the 
spine is recurved, so that the convexity is forwards instead of backwards ; 
this is most commonly seen in the cervical region : we have, however, seen 
it in the lumbar vertebras too. In such cases the bending is never sharply 
angular, but is due to spasm of the posterior spinal muscles ; it can rarely, 
if ever, be due to destruction of bone, for to produce such result, not only 
the bodies but the arches of the vertebrae would have to be destroyed I the 
condition is generally merely an exaggeration of the normal curves. 

Since there is a physiological curve with its convexity forwards in the 
cervical and lumbar regions, a certain amount of destruction of the vertebral 
bodies has^ the effect of merely straightening these curves, and it is only 
when considerable erosion has taken place that a curve with its convexity 
backwards is produced. 

Extensive disease of the posterior parts of the bodies may, of course, 
exist without any curvature, and in such cases the inflammatory material 
poured out may produce pressure on the cord or nerves, or inflammation 
by extension ; hence the old saying, ' The less the deformity, the more the 
paralysis.' x Paralysis in such cases is probably hardly ever due to bony 
pressure, since the spinal canal is not encroached upon ; this is only likely to 
occur where a sequestrum is pushed into the canal. 2 Lateral ' curvature 
sometimes results from destruction of the sides of the bodies and consequent 
collapse ; more often, however, any lateral curvature that does exist is a result 
of ligamentous and muscular weakness, and as such is a true lateral curvature. 

Before there is any permanent deformity from loss of material, certain 
characteristic attitudes are assumed by the subjects of spinal disease. In 
caries of the cervical spine the child often supports his head with his hands, 
to lighten the pressure upon the diseased spot and prevent any sudden jar, 
and is slow and careful in turning round and stooping. Where the dorsal or 
lumbar regions are involved, instead of bending the spine to reach any object 

1 It is also a matter of frequent observation that paraplegia and abscess are rarely 
associated. 

2 Paraplegia is commoner in cervical and upper dorsal caries than in disease lower 
down. 



Deformity in Spinal Caries 



717 



upon the floor, the child bends the knees and hips, and so brings down the 
hands, and at every opportunity assumes the resting position shown in fig. 167. 

It is most important to distinguish angular curvature from lateral curva- 
ture and from rickety spine. It is only in the very early and very late 
stages of disease that there is likely to be any doubt whether a case is one 
of lateral or angular curvature ; in ordinary well-marked cases the distinc- 
tion is clear enough. In some old cases of lateral curvature very sharp 
bends in the spine are much like 
angular deformity ; and again, we 
have more than once seen cases 
where there was an early lateral 
curve and no symptoms pointing to 
caries, yet in a few months un- 
doubted caries appeared. Careful 
and repeated observations are, there- 
fore, necessary if there is any possi- 
bility of doubt, and it must be re- 
membered that the two affections 
may co-exist. Ordinarily a diagnosis 
is readily made by the presence in 
the one of a lateral curve and of 
rotation, and by the fact that the 
curve in caries is abrupt, in lateral 
curvature gradual, as well as by the 
presence or absence of the other 
symptoms of caries mentioned. 1 

The rickety spine is distinguished 
by its being a general rounded curve, 
by the absence of rigidity, by the 
disappearance of the curve when the 
child is held so that the weight comes 
upon the spine, by the evidences of 
rickets elsewhere, and the absence of 
the characteristics of caries. Caries 
also is very rare in the first two years of life, rickety spine much more 
common during that period. 

With these exceptions, and the possible ones of an old fracture or dis- 
location, or congenital undue prominence of certain spines, or the develop- 
ment of bursae over the spines, the result of friction or pressure, angular 
deformity may be taken as pathognomonic of caries either present or pre- 
existing. 

Abscess is not by itself a certain indication, since it may be due to many 
other causes than spinal caries ; still, the presence of a lumbar, gluteal, iliac, 
psoas, post-pharyngeal, or cervical abscess should always lead to a careful 
examination of the spine. It must be remembered that pelvic disease, 
glandular, perityphlitic, perisigmoid, and perinephritic abscesses, empyema, 
carious ribs, sacro-iliac and hip disease, &c, may give rise to suppuration, 




Fig. 167. — Caries of the Spine, showing a cha- 
racteristic resting attitude, which should be 
contrasted with the rickety spine seen in fig. 38. 



1 See also a paper by Lovett of New York, 1890. 



7 1 8 Spinal Disease 

which may point in positions identical with those in which spinal abscesses 
may find outlet. 

Rigidity is a most important sign of spinal disease, important all the 
more because it is an early one ; the stiffness is due to spasm of the spinal 
muscles, just as in disease of any other joint. Rigidity is best tested by 
stripping the child and putting some object upon the floor for him to pick 
up ; by watching carefully it will be seen whether the whole spine bends as 
in health, or whether it is held stiff and immovable in any part. Healthy 
children freely bend their spines, but in order to fully test the mobility of the 
column the child should be told to keep its knees straight. Absence of 
flexibility is, taken alone, the most valuable sign of caries except deformity. 

In the cervical region, muscular spasm may give rise to wryneck, in- 
ability to nod or to turn the head round, according to the part involved. 

Besides contraction of the posterior spinal muscles, there may be rigidity 
of the ilio-psoas, causing flexion of, and inability to straighten, one or both 
legs : this usually means that a psoas abscess is beginning to form, and the 
muscles are rigid in consequence of irritation, or kept voluntarily contracted 
to prevent pressure upon the abscess. Local rigidity of the lumbar muscles 
or of certain of the posterior spinal muscles will sometimes be found ; thus 
the erector spinas may be seen tightly contracted and standing out promi- 
nently just above the sacrum. 

The test of bending the body backwards is more applicable to adults than 
to children, in whom it is difficult to estimate amounts of pain ; it should, 
however, always be employed. 

Muscular zuasting occurs in spinal as in other joint diseases, but is rarely 
well marked, except when the disease is far advanced, and hence is not of 
great value alone as a symptom. 

Dysphagia may result from pressure by an abscess upon the pharynx or 
oesophagus, or dyspnoea from pressure upon the trachea or lungs or upon the 
recurrent laryngeal nerves in disease lower down ; so too, possibly, extensive 
abscess in the chest may give rise to physical signs, dulness, &c. This is, 
however, more likely to be due to enlarged mediastinal glands. We have 
recently had a case in which severe and progressive dyspnoea came on in a boy 
with acute caries of the upper dorsal spine ; the disease was only of about seven 
weeks' standing, but there was a well-marked angular curvature. There was 
no paraplegia. Slight dulness was found on the right side near the spine, 
but no evidence of actual lung mischief sufficient to account for the dyspnoea. 
A portion of rib opposite the most prominent part of the curvature was 
excised and the head and proximal part of the rib, which were carious, removed. 
A considerable ' abscess ' was found in front of the spine, and all the 
pressure symptoms were at once relieved when it was emptied. 

Large abdominal abscesses may produce pressure effects upon vessels 
and viscera, but these are rare results. Abdominal distension from flatu- 
lence may be due either to pressure upon nerves or to failure of the digestive 
powers in later stages, or to coincident tubercular disease of the intestines, 
mesenteric glands, &c. 

The subjective symptoms of spinal caries are pain and loss of sensation. 
Pain may be acute or nothing more than a feeling of tiredness or aching ; it 
is usually an early and prominent symptom ; it may, however, be entirely 



Symptoms of Spinal Caries 7 ] 9 

absent, just as in some instances of chronic joint disease elsewhere. Usually 
there is pain over the affected spot, increased by pressure or jarring of the 
spine, such as may occur in jumping, or suddenly stepping down from a 
height ; in caries of the cervical spine, pressure upon the top of the head 
often causes suffering, and in any part of the column flexion or rotation 
movements may be painful. 

Further, there is usually pain in the course of the nerves passing out 
from the diseased area ; thus, in dorsal caries there is pain at the sternum 
or in the side ; in dorso-lumbar disease there is abdominal pain (' girdle 
pain ; ' so called ' dry belly ache '). Pains in the limbs, shooting down the 
legs over the distribution of the sacral and lumbar plexuses, and similarly in 
the arms, may be met with. Any obscure pain should always be carefully 
traced to its source by searching along the whole course of the affected nerve 
up to its origin. Thus, pain in the back of the head, so called ' headache,' 
may be due to pressure upon the occipital nerves, and so on. 1 

The anaesthesia and paraesthesia due to spinal caries are either the result 
of pressure upon the theca or nerves or of inflammation spreading from the 
bone to the meninges or cord, and will be found described at page 573. 

Pain in the spine is sometimes increased by the application of warmth, 
e.g. a hot sponge applied over the diseased part, but the symptom is not 
constant nor of any great value. In some instances we have found herpes 
zoster occurring in connection with caries of the spine, and it is worth while 
to examine the spine in cases of shingles, since the erruption may be a result 
of lesions starting in the spinal column. 

The conditions most likely to be confounded with spinal disease are, in 
the neck, sprains or stiff neck from cold, reflex irritation, &c, glandular 
inflammation, and cervical cellulitis. The ' vertebra prominens ' should be 
remembered, and the ease with which the cervical transverse processes can 
be felt ; there is often a deceptive feeling of thickening about the cervical 
vertebrae which is apt to mislead unless comparison is made with a healthy 
neck. In caries thickening will be felt In glandular abscess the glands 
themselves can usually be felt to be enlarged, and generally the pain is 
most marked or only exists on one side, -whereas in caries there is usually 
tenderness on pressure on both sides. This, with the other symptoms already 
mentioned, will serve to distinguish between the two conditions. Praever- 
tebral abscess, though often due to spinal disease, may be the result of 
several other lesions ; vide p. 78. 

Caries of the dorsal and lumbar spine has already had its distinguishing 
features pointed out ; it is only necessary to add that in all cases search 
should be made for evidence of abscess deep in the abdomen, since large 
collections of matter sometimes form very insidiously. 

Complications. — In addition to the troubles arising directly from the 
spinal lesions other complications may arise ; thus the vertebral disease may 
be only a part of a general tuberculosis in which viscera or bones and joints 
other than the spine may be involved. Sometimes a psoas abscess in track- 
ing down gives rise to disease of the sacro-iliac or hip joints {vide Hip 
Disease). As a result of pressure upon or inflammation of the spinal cord 

1 For illustrations of these peripheral pains the reader is referred to Mr. Hilton's 
admirable book, Rest and Pain, edited by Mr. Jacobson. 



/20 Spinal Disease 

and its membranes cystitis or paralysis of the bladder may result ; bedsores 
may form, both as a consequence of pressure and from the nerve lesions. 
Exhaustion, hectic, lardaceous disease, and general tuberculosis are the 
most common causes of death, though it must not be forgotten that sudden 
death may occur from displacement, the result of softened ligaments, in the 
upper cervical spine, or from bursting of an abscess into the air passages, or 
ulceration into a large vessel. In other instances pyaemia or other inter- 
current disease cuts life short. 

Paraplegia may occur in the course of spinal disease as a result of pres- 
sure from inflammatory exudation poured out into the spinal canal, from 
effusion pressing upon the nerve roots, an occurrence met with in the cervical 
region ('cervical paraplegia' of Gull), from necrosis and projection of a 
sequestrum into the canal, or rarely from the angular bending of the spinal 
column. Paraplegia occurs most frequently in cases of caries of some part 
above the lower dorsal spine, more rarely in lumbar disease. The degree 
of paralysis varies from mere weakness with paresthesia to complete 
paralysis of the lower limbs, the bladder, and the rectum ; or in rare cases the 
paraplegia maybe complete below the lower cervical region. There are loss 
of power, diminished sensibility, exaggeration of the reflexes, more or less 
contraction of the limbs, and, in cases where the cervical or lumbar enlarge- 
ment of the cord is involved, actual muscular degeneration. Pain may or 
may not be present. For details vide Chapter on Nervous diseases ; 
Paraplegia, p. 573. 

Mode of Repair. — Repair in the spine takes place just as in other joints ; 
the carious or necrotic process ceases, and the tissue injured beyond recovery 
is either thrown off and comes away in the discharge, or is encysted and 
remains quiescent, giving rise to no more irritation. The granulation tissue 
either develops into fibrous tissue or ossifies, and the adjacent bone surfaces 
are welded together ; in addition to this bony splints and buttresses are 
developed around the diseased spot and further strengthen it. 

It is possible in very early stages for the inflammation to subside, and 
the parts to return to their original healthy condition ; but once there is loss 
of substance the curvature is never lost, though the spine may appear 
straighter from development of compensatory curves, or from straightening 
out of other mere transitory yieldings due to muscular and ligamentous 
weakness. 

Treatjnent. — Disease of the spine requires treatment on exactly the same 
principles as disease of other joints, viz. rest and general hygienic measures, 
with such management of abscesses as each case may demand. 

The general treatment need not be specified here further than to say 
that nutritious and careful diet, iron, and cod-liver oil, together with good 
air — sea air if possible — are the desiderata. The difficulties arise in 
obtaining rest and in the treatment of abscesses. Rest implies absolute 
fixation of the diseased part : this requires different arrangements in caries 
of the upper and lower parts of the spine. In cervical caries the best plan of 
treatment is to put the child on a hard mattress, with a small pillow to fit 
in between the shoulders and occiput so as just to support the spine without 
straining it : a ring air or water cushion for the head answers very well. 
Sandbags not too tightly filled are then laid along each side of the neck, 



Treatment in Spinal Caries 



721 



packed well in, and secured by one placed across above the top of the head, 
a folded handkerchief should be carried across the forehead and fastened 
to the sandbags at the side to prevent any possible lifting of the head 
Arrangements should be made for defalcation, &c, without disturbing the 
child, by providing a hole in the mattress or a separate part in the middle 
that can be slid out. We know no better plan than this, as advised by Mr. 
Hilton, where it can be carried out rigidly, but it is difficult to manage for a 
sufficient time. Extension by means of a head sling and weights may be 
applied in cases of cervical and high dorsal caries {vide Schapps, ' Year Book 
of Treatment,' 1895, P- 2 7&). As soon as repair has fairly advanced, as 
evidenced by absence of pain for some weeks previously, loss of tenderness, 
and diminution of thickening, with drying up of any abscesses that may have 
formed, the child should have on a stiff leather or 
poroplastic collar moulded carefully to the neck and 
occiput, and shaped to the shoulders below ; he may 
then begin gently and carefully to get about for a short 
time daily, but on the least sign of pain or swelling the 
original plan must be reverted to. 

Or a jurymast may be applied with a plaster or felt 
jacket, either in the original form devised by Sayre, 
or of a shape we prefer as less troublesome, and we 
think more efficient, as shown in fig. 168 ; this form 
has the advantage of providing elastic support, of not 
requiring to be made of steel, and of not tending to 
press upon the vertex. The jurymast must be carefully 
modelled to the particular case, and never removed, 
but the straps kept just taut. Failing the treatment in 
bed, the jurymast is, we think, as good a plan as any, 
though it is troublesome to manage, and we seldom use 
it. Various other methods, such as inflatable rubber 
collars, sawdust collars, &c, are used with advantage 
in suitable cases, i.e. when the disease is subsiding. 
Extension of the head by weights, the trunk being 
fixed, is sometimes usefully employed, but requires 
care not to overstretch the softening ligaments. 

Caries in the upper and mid-dorsal regions requires 
as absolute recumbency as cervical disease, but it may 
be either in the prone or supine position, and sand- 
bags are not required ; the child should be fastened 
down by the simple plan shown in fig. 162 if he can- 
not be trusted to lie still. The jurymast plan is 
applicable, of course, to these cases as well, and must be used in any case 
where the ordinary jacket cannot be so applied as to carry the weight of the 
upper part of the body. 

The ordinary plaster-of-Paris Sayre's jacket is a useful appliance for spinal 
caries in the lower dorsal and lumbar regions. In acute and rapidly pro- 
gressing cases a period of recumbency should be insisted on, either with or 
without the jacket. Certain points are essential in the use of this appliance. 
1. Any sharply projecting spines must be protected by padding round them, 




Fig. 168.— A Jurymast for 
Cervical or Upper Dorsal 
Caries. The altered shape 
of the upright makes it 
easier to fit, and it is not 
necessary to have it of 
steel ; it also prevents fall- 
ing forward of the head 
without making abso- 
lutely vertical traction. 
The spring of the steel is 
replaced by elastic cords 
in the straps, which have 
been omitted from the 
figure for the sake of 
clearness. 



7 22 Spinal Disease 

and by careful moulding of the plaster to avoid pressure. 2. The jacket 
must reach well up to the root of the neck in front and behind, being shaped 
out in the axillae ; this may be done by carrying the bandages crosswise over 
the shoulders and cutting out the cervical part afterwards, or by careful 




a 



c^r~~"o 







CD £0 



fen 



nrrn 



rm. 



B 



I^Zg (JR| 




fw^m 



Fig. 169. — Patterns of Splints for Spinal Caries, Laminectomy, &c. A, for fixing head, trunk, 
and lower limbs ; B, for dorso-lumbar caries ; c, for upper dorsal ; D, for dorsal disease ; e, for 
dorso-lumbar laminectomy ; F, for fixing whole trunk and lower limbs in a case of lumbar or 
gluteal abscess, &c. These appliances are all Thomas's splints or modifications of them. 



adjustment of the turns without crossing the shoulders. 3. The lower 
border of the jacket must come down well over the crest of the ilium, so as 
to distribute the pressure and prevent the formation of sores on the crest 
and iliac spines. In fact, the jacket must be closely fitting and envelop the 



Sayre's Jacket 



723 



whole spine from neck to pelvis, and not be, as it too often is, a mere wisp 

round the waist. We used generally to apply these jackets in the out-patients' 

room, with the child lying on its face across two chairs with a gap between 

them ; the tripod may, of course, be used, but with the greatest caution, to 

prevent any stretching, and it must be remembered that the point in 

applying the jacket is to fix the spine and prevent any further pressure, not 

to pull the surfaces apart — it would be as 

rational to put on powerful extension and 

counter extension after excision of the knee, 

dragging the bones away from one another, 

as to try to extend a carious spine. Of the 

various modifications of the jacket we have 

no experience. With careful management a 

jacket will last from nine months to a year if 

the child does not grow out of it, but usually 

hospital patients require new ones every two 

or three months. The plan of putting on 

two jerseys and changing the inner one by 

tacking a new one to its lower edge, and 

then drawing it upwards beneath the jacket 

by pulling the old one over the head, is 

ingenious and saves frequent changing in 

some cases. Pain after a jacket is put on 

usually means pressure at some point, and 

should lead to careful examination : if at the 

hips or axillae, it may be relieved by 

judicious packing or cutting out : if in the 

back, the jacket must be removed, or it will 

cause sores. Free dusting between the jersey 

and the skin with powdered boric acid, or, 

in dirty people, with pulv. hyd. ammon., is 

useful. From six to eight bandages are 

usually required for a jacket in a child ; they 

should be applied in spirals so as to cross and 

strengthen one another, and care must be 

taken not to allow the edges to be thin and 

weak. ' Dinner pads ' are not necessary if 

the bandages are put on judiciously ; a soft 

patch in the jacket over the abdomen does 

not demand a re-application so long as the 

rest of the jacket is firm. In some cases, 

where, from the presence of abscesses in the 

"back, or co-existent hip disease, or flexion of 

the legs from psoas abscess, a jacket is inapplicable, we use a double 

Thomas's hip splint and find it very useful ; it ensures recumbency, keeps 

the spine at rest, extends the legs, and does not interfere with dressings 

nor require removal (figs. 169, 170). Should the child be fit to be on its 

legs, it can get about, with crutches, in a double Thomas's splint. 

Poroplastic and other jackets have only doubtful advantages over the 

3 a 2 




Fig. 170. — Caries of the Spine, with 
double ilio-lumbar abscess, treated 
b}^ the application of a double 
Thomas's splint. 



7 24 Spinal Disease 

original Sayre's, and have many drawbacks ; they are rather applicable as 
protections after consolidation has taken place than as a mode of treatment 
for active disease. Of the various special apparatus we can only speak 
in the same terms, but not from actual experience of them : we have never 
been tempted to try them. 

While we have described the management of Sayre's jackets and the jury- 
mast we have personally almost entirely given up their use in favour of absolute 
recumbency with or without a Thomas's spine splint. We believe no treatment 
is so good as absolute confinement to a recumbent posture, but it must be 
absolute ; there must be no raising of the body for washing or feeding or 
emptying the bowels. The best plan is to keep the child on a blanket- 
covered board on which he can be carried to and from bed and his day-room 
or spinal carriage. From this board he should never be raised, though he 
may be occasionally rolled over on to his side to sponge the back. 

If it were possible to reach and remove the source of suppuration in all 
cases, the management of spinal abscess would be that of all other abscesses 
in connection with bone disease, but the question is not a simple one, and 
each case has to be judged for itself. In cervical disease, as a rule, all 
abscesses should be opened as soon as they develop, for they are apt to track 
widely down the neck or, pointing in the pharynx, to become septic or a source 
of danger from pressure. Hence antiseptic incision, by dissection at the pos- 
terior border of the sterno-mastoid, is the best treatment. In one case where 
the disease was of the spinous process alone, we opened the abscess, and later 
removed the necrosed spine ; and this, perhaps, might sometimes be done in 
necrosis of the bodies as proposed by Mr. Treves more especially for lumbar 
necrosis. Opening the abscess in the pharynx is not a good plan, and should 
only be done in an emergency where the pressure is threatening suffoca- 
tion ; even then we should prefer to do tracheotomy and then open the 
abscess in the neck at leisure, allowing the tracheotomy wound to close. 

Abscess due to upper dorsal caries does not usually come to the surface, 
though no doubt it often exists hidden in the posterior mediastinum ; where if 
it gives rise to symptoms it may be recognised, as in the case related on p. 718. 
Abscess pointing in the lumbar, iliac, or psoas area is the condition most 
commonly met with ; as to its treatment, our opinion is that if the abscess is 
on the point of bursting, or gives rise to much pain, or is increasing, it 
should be opened at once with full antiseptic precautions — the opening- 
being made in the loin if there is any cavity there of sufficient size, or, if not, 
in some cases it is a good plan to pass a long probe from the lower opening, 
iliac, psoas, or gluteal, as the case may be, and cut down upon it in the loin. 
Where the abscess is small, chronic, and stationary, and where no adequate 
treatment has been hitherto adopted and there is not much pain, it is 
justifiable to wait. The pus may be absorbed, there may be no sequestra 
to keep up irritation, and the caries may subside with rest, while we cannot 
remove the disease if it does not subside. When once opened there is 
always the possibility of dressings slipping and the wound getting foul, with 
the usual result of slowly progressive or acute septic poisoning. But if the 
conditions mentioned above exist, or if the abscess is large or does not 
subside after a few weeks of absolute rest in bed, it is better emptied. All 
spinal abscesses, when opened, should be dealt with by the method already 



Spinal Abscess 725 

mentioned as suitable for chronic abscesses elsewhere — i.e. they should be 
opened freely, all their contents thoroughly wiped and washed out ; the wall 
of the abscess being thoroughly cleaned, the cavity should then be injected 
with iodoform emulsion and the wound closed. Should there be subsequent 
evidence of sepsis from imperfect management of the wound, it must be 
opened and drained, but this must be looked upon as a serious disaster. If 
however, the wound heals without fever, but the abscess gradually refills, 
the failure is due merely to incomplete removal of the diseased material, 
and the operation must be repeated as often as fluid re-collects. By this 
method excellent results will be obtained if, and this is the whole question, 
sepsis is avoided. As to lumbar exploration and removal of sequestra, the 
plan introduced by Mr. Treves, we confess we rather agree with Mr. Owen 
that, while opening the abscess as near the seat of disease as possible is of 
course good, it is but rarely that we can hope to make out the exact condition 
of parts or find the sequestra in situ, and the method is, as already pointed 
out, only applicable to lumbar disease. Nevertheless the abscess should be 
explored with the finger in order to ascertain the size, shape, and relations 
of the cavity, as well as to reach, if possible, the original seat of the disease, 
and remove any sequestra and wash or sponge out any caseous lymph lying 
loose in the abscess cavity. This is, of course, quite a different matter from 
cutting down upon vertebral bodies. It is not wise to scrape these abscesses 
or to use any strong antiseptic lotion, since anything more than gentle 
wiping out is apt to lead to bleeding from the wall of the cavity, and any 
strong lotion may be imperfectly emptied out of the cavity, and so may give 
rise to poisoning. 

Where paraplegia occurs strict recumbency in bed is the only treat- 
ment, with very careful general management and the utmost watchfulness to 
avoid bedsores. All discharges must be carefully cleaned away and the 
parts kept dry and powdered with boric acid. Occasional washings with 
strong spirit tend to harden the skin and prevent pressure sores. Any con- 
tractures of the limbs should be prevented as far as possible by suitable 
appliances. The internal administration of large doses of iodide of potassium 
is highly recommended by our friend Dr. Gibney of New York, but it has 
failed in our own hands. Mercury may be tried with advantage in some cases. 
Counter-irritation in the form of blisters or the actual cautery is sometimes 
of service. Where the paraplegia resists all treatment for a long time, the 
question of trephining the spine (' laminectomy ') and removing the source of 
pressure is to be considered. In one case in which we operated we removed 
a thick layer of lymph from within the spinal canal, and a paraplegia of six 
months' standing, which had resisted all other modes of treatment, at once 
began to improve, but the benefit was only temporary. In two of our cases 
complete recovery of power of walking followed the operation, but we limit 
its application to cases in which paraplegia has persisted, after at least six 
months' absolute recumbency. In cases where paraplegia has come on 
rapidly, and is due to pressure of an abscess, the operation should no doubt 
be done earlier (vide Thorburn, 'Brit. Med. Jour.,' June 30, 1894). Dr. 
Macewen has recorded some successful cases {vide Address, ' Brit. Med. 
Jour.,' Aug. 11, 1888). Within the last few years a great impetus has been 
given to this operation, and sufficient success has been obtained to fully 



726 Spinal Disease 

justify it in cases where paraplegia does not improve by long-continued rest. 
The cord may be compressed by sequestra or by an extradural abscess, or 
possibly by distortion of the spine, but most commonly the pressure is due 
to effusion of thick tough lymph on' the surface of the theca. For details of 
the operation we must refer to the special works on operative surgery. After 
the operation some such apparatus as that figured (fig. 169, A, c, or e) should 
be applied until the parts have consolidated. Our own experience is that 
the operation is seldom called for, and that the great majority of cases of 
compression paraplegia- improve by continuous rest in bed. 

Disease of the sacrum, with abscess pointing into the rectum, is a des- 
perate condition. The abscess is certain to be septic, and can only be 
reached through the rectum unless it has burrowed down to the sciatic 
notch, or points at the back, as it may do. In one case we tried to remove 
the disease, but in consequence of patency of the theca below its normal 
point it was wounded, and the child died of meningitis ; the post-mortem 
showed that any such operation would have been exceedingly difficult, and 
probably impracticable. 

The prognosis in spinal disease depends upon the stage to which the 
mischief has advanced, the presence of other tubercular lesions, and the 
amount of care that can be bestowed upon the case. It is not necessarily 
bad, and under favourable circumstances is decidedly good ; but from one 
to three years' treatment or even more is required. 

Atlanto-axial disease is, as already remarked, rare in children ; it is essen- 
tially the same disease as tuberculosis of any other joint, but its importance 
depends upon the effects liable to follow softening of the ligaments and 
sudden displacement of the odontoid process, viz. sudden death from pressure 
upon the upper cervical cord. Occipital pain, rigidity and thickening of the 
neck, with perhaps paresis, are the general symptoms ; there may be special 
difficulty in rotating the head. The general rules for cervical caries apply 
in other respects to this locality. 

Disease of the costo- vertebral articulations sometimes occurs, either 
alone, or as a result of extension from disease of the spine or a rib. Pain, 
which may be radiating, and formation of abscess, are usually the only 
symptoms by which the disease can be recognised. The abscess may point 
either in the back or lumbar region ; possibly some cases of psoas abscess 
depend upon this lesion. It is likely to be mistaken for spinal caries, but 
the absence of curvature, the slight, if any, rigidity, and the unilateral pain 
and suppuration, as well as the results of exploration, will probably enable 
the difficulty to be cleared up. Fixation in a plaster jacket with, if neces- 
sary, a window for discharge, or, better still, one of the appliances figured 
(fig. 169) is the best treatment if the disease is intractable. 



727 



the simple forms. 



CHAPTER XXXIII 

CLUB-FOOT, DEFORMITIES OF LIMBS, ETC. 

The deformity known as club-foot or talipes may be congenital or acquired. 
The varieties of the congenital affection are named as follows : 

Talipes varus 

„ valgus 
,, equinus 
„ calcaneus 
Talipes equino-varus ) , 

„ calcaneo-valgus } the compound forms. 

Talipes cavus may be simple or associated with equino-varus or equinus. 

The only common form of club-foot is equino-varus ; this deformity is 
sometimes called simply varus, but inasmuch as the distortion is a compound 
one in almost all cases, we shall consider it under the more accurate title — ■ 
and this is the more necessary, since its successful treatment largely depends 
upon recognition of this complexity. Calcaneo-valgus is the next most 
common form ; the others are only occasionally met with, and as great 
rarities anomalous forms such as calcaneo-varus and equino-valgus are 
seen. 

The general appearance of congenital equino-varus is seen in the figures. 
The heel is drawn up (equinus) and the anterior half of the foot is adducted 
and rotated inwards upon an antero-posterior axis, the adduction and 
rotation taking place at the transverse tarsal joint. Considering this 
deformity more in detail, it will be found that abnormalities exist in the 
muscles, ligaments, bones, and fascise of the foot, and, though the subject 
has long been under investigation, we owe to Mr. Parker and Mr. Shattock 
much of our information upon the share taken by these several structures 
in the maintenance of the malposition. We use the word ' maintenance ' to 
show that we believe that the deformity is due to persistent fixation of the 
foot in a distorted attitude rather than to any active displacement caused by 
muscular or ligamentous contraction. In describing the anatomy of talipes 
we acknowledge freely our indebtedness to Mr. Parker's work. 1 

In talipes equino-varus the posterior ligament of the ankle joint, the 
anterior part of the internal lateral ligament, and the astragalo-scaphoid and 
inferior calcaneo-scaphoid 2 ligaments are those which are especially tight. In 
addition to these the plantar ligaments and plantar fascia help to maintain 
the concavity of the sole of the foot which co-exists with the equino-varus. 

1 Congenital Club-foot, 1887. 

2 Constituting the ' astragalo-scaphoid capsule ' of Parker. 



728 Clubfoot, Deformities of Limbs, &c. 

In severe cases the whole of the ligaments on the inner side of the foot are 
shortened, and there may be adventitious fibrous bands. 

Besides the ligamentous structures, the tibialis posticus and anticus, as 
well as the flexors of the toes, the short muscles of the sole, and the muscles 
of the calf acting upon the tendo Achillis, contribute to the maintenance of 
the deformity, though it has been shown that, with the exception of the 
tendo Achillis, all the rest may be divided, and yet, unless the ligaments are 
also cut, but little effect can be produced upon the malposition. This is, 
however, not always the case, and it is probable that the share taken by the 
different factors in talipes is not always the same. Mr. Parker places the 
resisting structures in equino-varus in early life in the following order of 
importance : 

(i) The astragalo-scaphoid capsule. (2) The tendo Achillis. (3) The 
skin of the inner border of the foot. (4) The bony framework of the foot. 
(5) The other ligaments and muscles. 

As to the bones, the trochlear surface of the astragalus is increased poste- 
riorly and diminished in front, and the neck of the astragalus is lengthened 
and directed more obliquely inwards than normal ; the articular surface on 
the head lies further inwards than usual. The ' calcaneum lies in a position 
of exaggerated rotation inwards beneath the astragalus, and in one case was 
found fused with the navicular.' The lower ends of the tibia and fibula are 
rotated inwards. The exact form of the astragalus appears to vary with the 
severity of the case. 

The drawing up of the os calcis tends to throw the head of the astragalus 
downwards, and the front of the foot is inverted at the transverse tarsal 
joint, and so the scaphoid slips partially off the astragalus and comes to 
articulate with the tibia. The cuboid, cuneiform, and metatarsals are also 
rotated inwards, and further retracted by the long and short muscles so as 
to contract the sole of the foot, thus producing cavus. In some cases all 
the tarsal bones show a tendency to curvature with the concavity inwards, 
and the direction of their articular surfaces is altered. The fibula may lie 
entirely behind the tibia, and the tendo Achillis, being brought close to the 
inner ankle, may lie nearer the posterior tibial artery than in the normal 
foot. In a case we dissected the flexor longus digitorum lay directly over 
the tibialis posticus. Bursas are found over the prominences of the foot, and 
may exist even in intra-uterine life. 

In early stages and slight cases it appears that the astragalus is natural 
in appearance, in more severe deformity it is wasted and the neck deviates ; 
there is not, however, any constant relation between deviation of the neck 
and deformity. In one or two cases that we have seen the deviation of the 
foot inwards was, we thought, at the scapho-cuneiform, not at the transverse 
tarsal joint. The ordinary result of these changes is adduction and rotation 
inwards of the front half of the foot, with elevation of the heel (figs. 171, 172). 

In valgus the whole foot is everted at the ankle or the subastragaloid 
joint, as well as rotated outwards at the transverse tarsal joint ; a and, further, 
the sole is flattened, or in infants oftener convex downwards, the tibialis 
posticus and calcaneo-scaphoid ligaments being stretched and the peronei 
shortened. 

1 So that valgus is not the exact opposite of varus. 



Talipes Equino-vams 



729 



In equinus the tendo Achillis and posterior ligament of the ankle joint 
are shortened and the astragalus is drawn back, so that only the front of the 
trochlea is between the malleoli ; there are other less important displace- 
ments of other tendons. 1 Talipes equinus is said to be an exceedingly 
rare condition as a congenital deformity ; we have seen a very pure example 
in which intra-uterine pressure marks upon the knees and shoulders were 
very obvious. In calcaneus the chief contracted structures are the ex- 
tensors of the great and lesser toes, the tibialis anticus, and the anterior 
ligament of the ankle joint ; thus the foot is flexed upon the leg and the patient 
walks upon the heel ; the front of the foot may be much atrophied. The 
trochlear surface of the astragalus is prolonged forwards as far as the navicular 
facet, and the inner malleolar surface is prolonged forwards (Parker and 





Fig. 171. — Severe Talipes Equino- 
Varus. 



Fig. 172. — Very severe Talipes Equino- 

Varus. 



Shattock). We have noticed extreme projection backwards of the os calcis 
in congenital calcaneus, as if the foot were partially dislocated backwards at 
the ankle, a deep depression existing over the front of the joint. Hollow 
club-foot (cavus) depends upon shortening of the muscles of the sole of the 
foot and the plantar ligaments, as well as the flexors of the toes, the tendo 
Achillis, and tibialis posticus. By the arching of the foot and the drawing 
up of the heel the extensors of the toes are put upon the stretch, and hence 
the toes are drawn up in hyper-extension, so that the deformity known as 
' hollow claw-foot ' is usually produced. 

The compound forms of talipes need no special description, as they 
consist of combinations of the simple varieties. 2 

1 Vide Mr. Parker's book. 

2 Holmes Coote, in St. Burth.'s Reports, vol. ii. 1866, describes a form of talipes 
consisting in rigidity of the tendo Achillis with subsequent development of flat-foot, of 



73° Club-foot, Deformities of Limbs, &c. 

Etiology. — Many theories have been proposed to account for the occur- 
rence of club-foot, and it is possible that most of them are true in certain 
cases ; we do not think any one cause alone will explain all cases of club- 
foot, though the great majority are due to malposition in ictero. 

Little considered talipes due to ' a morbidly excitable, retractile disposition ' 
of muscles, comparable to the reflex torticollis of later life. 

Central and peripheral nerve lesions, causing spasm or paralysis of 
muscles, may account for some cases, where, for instance, spina bifida or 
absence of brain (anencephale) is associated with talipes ; on the other 
hand, Parker and Shattock found both cord and nerves perfect in a case 
they examined. In opposition to them, however, we must point out that the 
nutrition of the talipedic limbs is often impaired, and they are fat, flabby, 
and toneless ; ' the muscles may, however, react normally to electricity. 
Intra-uterine pressure associated with deficient amniotic fluid (Cruveilhier)is 
no doubt the cause in some children. We have found talipes associated 
with intra-uterine constrictions and amputations from amniotic bands,' 2 and 
in another case, alluded to above, the deformity co-existed with pressure 
marks ; but the distortion is also found where the liquor amnii is abundant, 
and such explanation hardly accounts for single talipes as the only mal- 
formation. 

A persistence of the natural early fcetal position (Eschricht) explains 
some cases (of equino-varus and, later, calcaneus) ; in others, again, deficient 
development of parts in the cause, as in cases where congenital absence of 
the fibula has produced valgus, and this may be compared with fig. 186, of 
absence of the radius producing club-hand. 3 Hueter supposed that obliquity 
of the neck of the astragalus was a cause, but, as shown by Parker, this may 
occur without talipes, and talipes may exist without it. Intra-uterine joint 
disease possibly explains some cases, and adhesions are found in certain 
instances in the joints. Cruveilhier, Forster, 4 Parker and Shattock, and 
Silcock have pointed out that w r here the limbs are interlocked in abnormal 
positions they will exert pressure on each side quite independently of the 
amount of fluid ; we have frequently seen cases where clearly the feet had 
interlocked : the one foot, being in a position of extreme calcaneo-valgus ; 
was received into the concavity of the other, which had severe equino-varus. 5 
For further discussion of the subject we must refer to the admirable works, 
so often quoted, of Messrs. Parker and Shattock, and, in acknowledging our 
indebtedness to them, we can confirm many of their observations by our 
own ; we think that nearly, but not quite, all of the cases can be explained 
mechanically by pressure or position in utero, bad packing as it were, and 

which it appears to be an early stage ; he calls it 'rectangular talipes equinus,' the foot 
keing kept at a right angle with the leg. 

1 Possibly this may be explained by the absence of natural exercise in utero, when the 
feet are interlocked or misplaced. 

2 Parker and Shattock also mention a case of theirs. 

5 Club-hand is, however, probably the result of pressure causing arrest of development 
of the prae-axial border of the limb. 

4 Missbildnngen des Menschen, Taf. xxvi. fig. i., from Cruveilhier ; the figure is copied 
in Bodenhamer, as the subject had also imperforate anus. 

5 Confirmation of this view of the causation of talipes is found in the other deformities 
similarly produced, such as ' genu recurvatum, &c.' Vide figs. 188, 189. 



Etiology of Club-foot 731 

so-called 'club-hand' is, we believe, due to the same cause. One of the 
strongest proofs, to our mind, is the tendency seen in children to assume, 
long after birth, the position they occupy i?i utero, with the feet or hands 
locked in the talipedal attitude (fig. 173). The result of habitual positions in 
producing curved bones in rickety children is interesting also in this relation 
{vide fig. 40). 

It is sometimes said that talipes is merely an arrest of development, a 
' failure to unwind ' the foot from its earlier or later foetal position : we 
think this hardly fully expresses the truth, there is something more ; an 
actual pressure and squeezing together of the parts in an abnormal position 
is certainly what has occurred — in most of the more severe cases at any rate. 

As to the degree of deformity, we cannot do better than quote Mr. 
Parker's words : ' When the cause begins to act very early in, and continues 
throughout, intra-uterine life, the deformity will be a very fundamental one ; 
whereas, if the cause begins to act at a later period, or if it be continued for 
a short time only, the re- 
sulting deformity will be 
less severe.' — ' Brit. Med. 
Jour.,' October 27, 1888. 

The treatment of all 
cases of club-foot in chil- 
dren can be successfully 
carried out without any but 
the most simple apparatus, 
except in the instances 
where, from neglect, old 
cases may require tarsec- 
tomy ; we shall, therefore, 
confine ourselves to de- 
scription of the methods 
we have found most useful, 
and omit all reference to 
costly and complicated appliances. The general principles of management 
are the same for the different forms of club-foot, so that we may take an 
ordinary case of equino-varus as a type. Several questions have to be 
considered, such as (1) When is treatment to be begun ? (2) Is a cutting 
operation to be performed ; if so, what structures should be divided, and at 
what age ? (3) When operation is required should all the tense structures 
be divided at the same time, and should reduction of the deformity follow 
immediately on the operation or be delayed ? (4) What is the best apparatus 
to apply? (5) How long is treatment to be continued. 

(1) It might be thought unnecessary to insist upon the treatment of club- 
foot being begun immediately after birth, but we have more than once had 
cases, several months or more old, brought for relief, in which not only had 
nothing been attempted, but the friends had been told the child was not old 
enough for any treatment yet. Of course with a child a few days old more 
can be done in a week than is possible in a month with an older child. Treat- 
ment should be begun without a day's delay. (2) The question of tenotomy 
has been allowed to become largely one of fashion, some surgeons advising 




Fig. 



'3. — Showing how Talipes is produced by ' bad pack- 
ing.' (From a photograph bj- Mr. C. S. Ashe.) 



732 Club-foot, Deformities of Limbs, &c. 

it in nearly every case, and others insisting not only on its needlessness, 
but upon the harm resulting from it. The rules we follow on this point are : 
If the child is seen within the first few weeks of life, operation is very rarely, 
if ever, necessary. During the next two or three years two points have to be 
considered : first, what amount of care can be expended upon the case ; and 
secondly, how rigid are the resisting structures, i.e. can the deformity be 
reduced by moderate force ? If the child can be thoroughly well looked after, 
and its splints applied regularly and intelligently, operation is not neces- 
sary in most cases under two years old, although it undoubtedly shortens 
the time required for reduction, and is sometimes desirable — certainly so 
where there is much rigidity, and any doubt about the efficiency of the care 
and management. Where the rigidity is so great in a child over three 
months old or thereabouts that the deformity cannot be completely reduced 
by reasonable force, operation should at once be performed ; such cases are, 
however, comparatively rare. We see no advantage in forcible ' redresse- 
ment' over a cutting operation. (3) In equino-varus if all the resisting 
structures are to be divided, those which maintain the varus part of the 
deformity as opposed to the equinus may be cut at the same time, and before 
there is any attempt to remedy the equinus, or both may be done at the one 
sitting. The plantar fascia rarely requires division except in neglected cases. 
Authorities differ as to the risks of immediate reduction after tenotomy. We 
do not think the matter is one of great importance, and generally settle 
the question by the interval that is to elapse before the next visit ; if more 
than two days, we usually correct the deformity at once. (4) As to the 
question of apparatus, we may say at once that we have never used, or seen 
the advantage of, the more complicated instruments — shoes modified in 
various ways from Scarpa's, taliverts, and so on ; they are too expensive for 
the hospital class, and in all classes we are quite satisfied with the results to 
be obtained by much more simple means. 

Practically we find one of three appliances will meet almost every case ; 
two are of Dr. Little's invention, and the third is a slight modification of 
Barwell's artificial muscle plan. To take a case of equino-varus in which 
the varus is to be remedied first. The first appliance is adapted only to 
infants or children a few months old. It is simply a strip of thick block- 
tin long enough to reach from the knee to just beyond the end of the toes 
when the foot is pointed (fig. 174). This is bent to fit the foot along its 
outer side in its full equino-varus position. It is then bandaged on, no 
attempt being made to remedy the equinus or varus ; when it is securely 
fixed to the leg and foot, the front of the foot (i.e. the part beyond the trans- 
verse tarsal joint), together with the tin, is gently bent outwards so as to 
slightly improve the varus, leaving the equinus unaltered. The foot is left 
in this position till the next day, or longer if absolutely necessary, when the 
bandage is re-applied and a little further correction employed, and so on till 
the varus is somewhat over-reduced. The equinus is then dealt with in the 
same way, the splint being applied to the back of the limb. The second 
appliance (fig. 176) is simply Dr. Little's tin splint. It may be used with the 
foot-piece fixed at a right angle with the leg-piece, or better movable, so as 
to remedy the varus alone first. This splint is applicable to older and more 
rigid cases, as it is a much more powerful appliance than the last. It is 



Appliances for Club-foot 



733 



useful sometimes to have a slit cut in the metal at the angle between the 
leg and foot pieces running a little distance along the edge of the sole ; 
through this slit the bandage is carried, and so the heel is more securely- 
fixed down. The third apparatus is Barwell's artificial muscle, applied 
somewhat simply. We use it in two different forms. The first form consists 
of Mr. Barwell's strip of tinned iron strapped to the front of the leg ; on it is 
soldered a hook. A strip of strapping, or webbing, or felt is carried round the 
front of the foot, and to its free end is fixed a loop of stout indiarubber cord 
or drainage tubing ; this is then stretched up to the hook above, so as to 
correct the deformity. The second way of applying the muscle is that 
shown in fig. 175. The object of using the straps instead of the tin 
splint and plaster is to allow the apparatus to be taken off in order to rub 
and wash the leg, friction being a point to which we attach considerable 
importance, as tending to prevent, or at least remedy, the great muscular 
wasting which occurs in the course of the treatment of talipes if any rigid 



Fig. 174. — Little's plain 
Tin Splint. 





Fig. 176.— Little's Tin 
Talipes Shoe, which 
may have a joint at 
the junction of the 
sole and leg pieces. 



Fig. 175.— The Artificial Muscle Appliance shown correcting the deformity in 
a case of Congenital Equino-varus (from a photograph), a, the rubber strap 
or ' muscle ; ' B, strapping round the foot ; c, the side straps connecting the 
upper and lower straps. The apparatus is a modification of Barwell's original 
plan. It is better to have the straps made to lace up than to buckle. 

appliance is kept on constantly. The plan we adopt usually is to use one or 
other of the tin splints, generally the first, until the deformity is so far 
corrected that the muscle can be efficiently applied ; the latter is then worn 
till the cure is complete. 

As to the duration of treatment no hard-and-fast rule can be laid down ; 
it varies in each case with the rigidity of the parts, the age of the patient, 
and the care expended upon it. In one case a few weeks, in another many 
months, may be required before the artificial muscle stage is reached. As 
soon as this can be profitably applied the drudgery of the task is over, but 
the case cannot be considered cured ; hence the answer to the fifth point, 
that of the duration of treatment, can only be general. As Dr. Little points 
out, no case is safe from relapse until the patient is old enough to watch him- 
self and correct the earliest sign of return of the deformity, although by the 
use of the artificial muscle another dictum of his, that there must be no 
walking till the deformity is remedied, may be set aside. Great care is 



734 Club-foot, Deformities of Limbs, &c. 

required, in applying the splints, not to be deceived by the rotation of the 
limb, and until the artificial muscle can be applied so as to slightly over- 
correct the deformity no walking is to be allowed ; after this point is reached 
it does no harm, but rather good. The essence of the matter is largely in 
the amount of trouble taken with each case by the surgeon and the friends. 
Some other points in management must be also considered. Manipula- 
tion, i.e. firmly holding the foot in a slightly over-corrected position, is 
exceedingly useful, and should be daily employed each time the splints are 
removed — or if, unfortunately, from pressure sores or other causes, the 
apparatus has to be left off, frequent manipulation prevents time from being 
lost. The leg should be firmly grasped in one hand, in such position that 
the patella looks directly forwards, and then the other hand should be used 
to steadily turn the foot into position, bearing in mind, in each case, the seat 
of the deformity ; thus in varus the ankle joint must be steadied and the 
rotation made at the tranverse tarsal joint. 

Pressure sores are to be avoided by regular daily renewal of apparatus, 
and avoidance of rucking up of plaster or bandages ; though, perhaps, 
strapping is more apt to cause sores than webbing, 1 it is easier to keep on 
in the early stages of treatment ; we, however, generally use thin saddler's 
felt or webbing" for the foot-strap, and carry it round the ankle and foot in the 
fashion shown in fig. 177, but reversed. 

Should it be decided that tenotomy is required in a given case, the rules 
for its performance are as follows. To divide the tibialis posticus the limb 
is laid upon its outer side upon a firm pillow, the posterior border of the 
tibia is felt for, and the tenotome passed in two fingers' breadths (in an infant) 
above the inner malleolus, in such position that its point justs hits the edge 
of the bone ; the knife is then slipped close to the bone, between it and the 
tendon, and its edge turned towards the tendon ; the foot is then held so as 
to correct the deformity, and by a gentle levering motion the tendon is 
divided, cutting towards the skin ; as soon as the tendon is felt to snap, the 
knife is withdrawn and a collodion pad and bandage applied. Occasion- 
ally bleeding is free, but readily stops on pressure, and no bad result 
follows. If the edge of the tibia cannot be felt, a point midway between the 
front and back of the limb marks its position. The better plan is to divide 
the tibialis posticus, together with the ligaments, through one puncture 
opposite the transverse tarsal joint in the posterior crease of the sole. 

The tibialis anticus is best divided upon the dorsum of the foot, just before 
its insertion into the inner cuneiform ; it is easily felt, and the knife passed 
beneath it, and division effected as in the posterior tendon. 

The tendo Achillis is perhaps the simplest of all. It should be cut 
about f inch above its insertion, at its narrowest part, the knife being passed 
well beneath it (i.e. nearer the tibia), from the inner side while the limb lies 
on its anterior surface. Personally we prefer to pass in the knife while the 
tendons are held tense and can be plainly felt ; others prefer to tighten only 
after the tenotome is beneath the muscle. 

We are much in favour, in suitable cases, of Mr. Parker's plan of dividing 
all rigid structures at the transverse tarsal joint, and not limiting the section 
to the tendons or fascia. The tubercle of the scaphoid should be felt for 
1 Vide Golding Bird, Guy's Hospital Reports, 1882. 



Treatment of Talipes 735 

and the knife passed in at the inner border of the foot, just behind the bone ; 
the edge is then turned towards the joint and made to cut well into it, 
dividing everything until the foot readily yields ; by thus severing the 
ligaments subsequent reduction is rendered much easier. Where this plan 
is adopted, the tibialis posticus and anticus are divided at the same time as the 
rest of the rigid structures ; the internal plantar artery is necessarily cut, and we 
have once seen a traumatic aneurism result, but no serious ill effect need be 
feared, even if bleeding is free at the time. 1 The anterior and posterior 
ligaments of the ankle joint require division in some cases of calcaneus 
and equinus respectively. 

It should be remembered that in second tenotomies the characteristic 
snap is often not felt. 

We are not satisfied with the results of fixing feet in plaster of Paris, 
either with or without tenotomy, but much prefer an arrangement where the 
pressure may be altered frequently. 

Where the artificial muscle plan is being employed, if tenotomy is re- 
quired at all, it is usually the tendo Achillis that needs division, since the 
plaster is apt to slip up towards the heel in such cases. Where the other 
splints are used, it is better, if the varus is corrected first, to divide the 
tibial tendons, &c, three or four weeks before the tendo Achillis ; some 
surgeons prefer always to divide the Achilles tendon first. The peronei rarely 
require division (we have never seen a case suitable for peroneal tenotomy) ; 
if they do, the section is made two fingers' breadth above the outer malleolus. 
The extensor longus digitorum and proprius hallucis may be divided just below 
the annular ligament, but we have never found the operation necessary. 

Congenital valgus is best treated by a muscle applied so as to exert 
pressure in the opposite way to varus ; it is, however, not so readily corrected. 
The rare equinus requires muscles on both sides to draw up the toes, usually 
after tenotomy. Calcaneus is best treated by the tin strip (fig. 174) or the 
jointed form of the splint (fig. 176). 

Talipes cavus is often remedied by division of the tendo Achillis only ; 
in other instances the resisting structures in the sole may require section. 
Where there is much cavus with equinus it is sometimes necessary to attach 
the ' muscle ' to a thin metal plate moulded to the balls of the toes, to prevent 
the foot strap from slipping into the hollow of the sole. 

There is no doubt that tenotomy alone is in many cases inadequate, and 
has been, with the exception of division of the tendo Achillis, largely given up 
in favour of the more complete and scientific operation of ' syndesmotomy ; 
(division of ligaments) described by Parker. Of ' open division ' of all the 
resisting structures, including the skin, we have little experience ; we have, 
however, had one or two cases in which after ' syndesmotomy ' at the trans- 
verse tarsal joint the skin has given way under the strain of forcible reduction 
of the deformity. The only harm resulting has been delay in the healing of 
the wound and some little increase in difficulty in the application of the 
' muscle.' The principle of the plan does not commend itself to us. 

Excision of one or more bones of the tarsus for inveterate club-foot, as 
employed by Davies Colley, Davy, Lund, and others, is an operation to be 

1 Other cases of aneurism following division of the plantar fascia are on record — vide 
Walsham, Lancet, January 28, 1888. 



736 Club-foot, Deformities of Limbs, &c. 

reserved for severe cases in older children, and only employed when there is 
no hope of remedying the deformity by other means. 

The operation we prefer consists in makinga _|_-shapedor oval incision on the outer side 
of the foot, the horizontal limb running along the outer border, and the vertical part passing 
across the centre of the cuboid. The Haps are reflected, the bones exposed, the tendons 
being drawn aside, and a wedge of bone is removed entire or piecemeal from the outer 
side of the foot; a chisel is the most convenient instrument for the purpose. Various lines 
of section are employed, but the general rule is to remove the cuboid always, and as much 
of the adjacent bones as the individual case may require ; the cuneiforms, head of the 
astragalus, bases of the metatarsal bones, and front of the os calcis may all require to be 
taken away. 1 After the operation the foot should come readily into position ; all bleeding 
having been stopped, and the dressings applied, the limb is at first fixed lightly on a back 
splint. The wound often heals somewhat slowly, and until it is superficial we prefer not 
to use forcible corrective apparatus ; usually in about a fortnight the muscle may be applied. 
It is a good plan to take away an oval piece of the thick callous skin and the under- 
lying bursa from the dorsum of the foot. We look upon the operation as a very valuable 
one in suitable cases — for instance, where the patient walks upon the dorsum of the foot 
and pressure sores are prone to develop, while all the structures are rigid (vide fig. 172). 

Excision of the astragalus alone, we think, is best adapted for paralytic cases — in such 
instances we have removed the bone with excellent results ; it maybe done without division 
of any important structure, by an incision over the ankle joint, carried from the tibialis 
posticus to the tibialis anticus, and another one at right angles to this, along the inner 
border of the latter tendon. By a little careful dissection the bone can be got out, the 
only difficulty being with the interosseous ligament. After the operation a shapely foot 
with a good arch still remains. Other incisions may be used. 

The most common forms of paralytic (acquired) Talipes are equino- 
varus and valgus ; these, so far as the deformity goes, are usually readily 
treated by the artificial muscle method, and the effect is generally immediate 
and to a certain extent satisfactory ; it does not, of course, remove the weak- 
ness and flabbiness of the foot, but it prevents actual turning outwards or in- 
wards, and makes walking much steadier and more sightly. In some few cases 
light steel supports are of value. Where, however, from long neglect the 
deformity is irremediable by these means, the method of excising the astragalus 
already described may be required. In very severe cases of infantile paralysis, 
where the foot is perfectly powerless, and especially where the paralysis ex- 
tends above the knee, and the knee joint is flexed, the limb being flail-like, 
short, and useless, amputation may be required ; this, however, should never 
be done in childhood, since there is a possibility of improvement. The 
attempt to convert the flail-like distorted limb into a stiff stable support by 
resection of the knee and ankle joints (' arthrodesis ') has been tried, with satis- 
factory results, in some cases ; in a case we operated on in 1884, there was 

1 The principal modes of tarsectomy are : 

1. Excision of a wedge of bone, irrespective of joint lines (Davies Colley). 

2. ,, ,, cuboid (Little). 

3. ,, ,, astragalus (Lund) (chiefly, we think, applicable to acquired talipes). 

4. ,, ,, astragalus, cuboid and scaphoid (West). 

5. ,, ,, wedge from the neck of the astragalus (Hueter). 

6. Linear osteotomy of the tarsus or of the leg above the ankle joint (Hahn). 

7. Excision of a wedge from the transverse tarsal joint, &c. (Rydygier) : vide Rydy- 
gier, Berlin. Klin. Woch. February 5, 1883; also Lorenz, Wiener Klinik, 1884, H. 5 
and 6 ; also Goldschmidt, Rev. Mens, des Maladies de VEnfance, from Centralbl. f. Chir. 
No. 17, April 1884, 



Acquired Talipes J^y 

very considerable improvement — this was, we believe, the first case operated 
upon in this country. Further experience has proved to us the great value 
of this operation in suitable cases. Walsham x has practised shortening the 
tendons by excision of a part and suture of the divided ends, thus correcting 
the deformity and allowing the lax muscles to act ; we have also tried the 
plan, with fair results in two or three cases. It is sometimes of much value. 
Goldthwait and others have employed the method of attaching healthy 
muscles to the tendons of paralysed ones so as to restore the lost power of 
the limb, a process of muscle grafting or myoplasty. Good results have 
followed in some cases. We have tried it, but our experience of the operation 
is not sufficient to justify 
an opinion as to its value. 

These paralytic limbs 
are, of course, prone to 
become the seat of chil- 
blains and ulcers from 
defective nutrition. 

Apart from the cases 
above mentioned of para- 
lytic talipes, where the 
structures are loose and 
flabby, are the deformities 
in which contractures 
have taken place as a 
result of paralysis of cer- 
tain groups of muscles. 
Of these the most com- 
mon are talipes cavus 
(arcuatus or plantaris), in 
which after paralysis of 
the extensors of the foot 
the muscles and liga- 
ments of the sole and 
calf contract, producing 
varying degrees of de- 
formity and concavity of 
the sole of the foot, 
together with elevation of the heel (equinus). In some instances the pointing 
of the foot produces secondary retraction of the toes (hollow claw-foot) by 
the strain of the extensors of the toes. The distortion resulting from the 
conflicting forces occurs mainly at the ankle joint, the medio-tarsal and the 
metatarso-phalangeal joints. All grades of deformity are met with, from 
slight exaggeration of the arch of the foot to the most' extreme equinus. 
Much more rarely the converse deformities are met with (fig. 178). 

In slight cases, manipulation or the use of artificial muscles without any 

operation will remedy the distortion, but in the severer forms of old-standing 

cavus and equinus, division of the tendo Achillis, or of more or fewer of the 

resisting structures in the sole, will be required. After operation an artificial 

1 Brit. Med. Jour. June 1884. 

3B 




-Acquired Talipes following measles, probably due 
to infantile paralysis. 



738 



Club-foot, Deformities of Limbs, &c. 



muscle should be used, and kept on till all tendency to re-contract has 
ceased. In troublesome cases of 'cavus' we attach the artificial muscle to 
a thin steel sole plate, which is modelled to fit over the balls of the toes, 
and so get over the difficulty of the tendency of the foot strap to slip into 
the hollow of the foot. Some good figures of these cases are given in a 
paper by Mr. F. R. Fisher, ' Lancet,' January 19, 1889. 

Patients, the subjects of club-foot, often suffer from complications of this 
condition. Bursas develop over the points upon which pressure is made, and 
these may become inflamed and suppurate, giving rise to obstinate sores, 
which will not heal and acquire callous edges. In some cases rest and 
ordinary treatment suffice, in others tarsectomy or even amputation may be 
called for. Pirogoffs or even Chopart's operation should usually be done 
in such cases in preference to Syme's amputation. 

The whole foot and leg in severe cases is smaller and weaker than the 
other, and often shorter. The wasting of muscles, &c, is extreme in 

some instances, even when no 
paralytic condition has existed. 
The movements of the ankle- 
joint become altered, and it de- 
velops into a ball-and-socket 
rather than a ginglymoid joint 
(Jorg). The metatarsal bones 
are usually shorter than normal, 
a condition due to the contraction 
of the plantar fascia, according to 
Borck. 

Treatment of club-foot in all 
cases must be kept up constantly 
until all tendency to relapse 
ceases. Dr. Little remarks that 
such patients require watching 
until puberty, and, as already 
pointed out, the result depends 
entirely upon the amount of care 
and perseverance expended upon 
them. 

Relapsed club-foot after teno- 
tomy is much more difficult to treat than it is in cases where nothing has 
been done ; tenotomy should, however, be repeated and the usual methods 
carried out. 

Plat-foot.— Apart from congenital and paralytic valgus is the common 
condition known as spurious valgus, pes pronatus acquisitus, pes planus, or 
commonly flat-foot. Though this affection is not by any means peculiar to 
childhood, it most commonly comes on in the later years of childhood or 
adolescence ; sometimes, however, it occurs earlier (fig. 34 etseg.). 

The condition is essentially one of relaxed ligaments and muscles, and 
comes on usually in weakly overgrown children, who have been kept too 
much on their feet— especially if they are rickety also. It is one of the 
conditions arising in so-called ' rickets of adolescence.' 




Fig. 178. — Acquired Talipes calcaneus, 
infantile paralysis. 



Flat-foot 



739 



The prominent part assigned to relaxation of the inferior calcaneo- 
scaphoid ligament in the production of flat-foot is hardly deserved, since the 
tibial muscles, the flexors of the toes and pollex, the short sole muscles, the 
plantar ligaments, the plantar fascia, and the peroneus longus all take a 
share in supporting the arch, and the condition is in most cases the local 
expression of a widely spread weakness rather than the result of yielding of 
any one structure. In a few cases flat-foot is the result of injury. 

Lowering and inward projection of the head of the astragalus, with loss ot 
the arch of the foot and its elongation, are the prominent features of the 
affection. The sole may be flat or even convex, and the inner border early 
becomes convex also ; there is usually pain over the head of the astragalus, 
often also across the dorsum of the 
foot and beneath the outer malleo- 
lus, and very commonly also in the 
first metatarso-phalangeal joint (one 
form of 'metatarsalgia'). Often 
the patient applies for relief entirely 
because of the pain in this joint. 

The prominent projecting mass 
on the inner aspect of the foot is 
not, however, by any means always 
the head of the astragalus only ; it 
is often the tubercle of the scaphoid, 
since this bone is frequently pressed 
downwards and inwards by the 
astragalus, so that yielding takes 
place rather at the scapho-cunei- 
form than at the astragalo- scaphoid 
joint. In some cases the promi- 
nence is shared equally by the 
astragalus and scaphoid. In any 
case where the deformity is marked 
there is a deep depression on the 
dorsum of the foot, due to the 
slipping away of the head of the 
astragalus. 

In early stages the deformity is 
only seen when the patient is standing, when the whole foot may be seen to 
collapse and spread out in a toneless fashion, the transverse arch also giving 
way. In later stages the foot becomes fixed in its distorted position, and 
cannot be replaced. In intermediate stages replacement is possible ; some- 
times in manipulating the foot adhesions give way and the arch is restored 
for the time. These adhesions are the result of chronic inflammatory 
changes which are specially prone to occur in the metatarso-phalangeal 
joint of the great toe, but may attack several joints and the sheaths of the 
tendons. Occasionally a violent spasm of the tibial muscles is seen pulling 
the foot into a position of varus — this is a sort of expiring effort, and when 
it is over flat-foot is seen. 

The treatment of this disease consists in preventing the child from 

3 B2 




Fig. 179.— Flat-foot in a boy aged 13I years. 



740 Club -fool, Deformities of Limbs, ere. 

standing long at a time, and improving its general condition ; next, the 
deformity must be reduced ; in ordinary cases an artificial muscle, applied 
so as to support the head of the astragalus, is perfectly efficient in relieving 
pain and restoring the arch of the foot, and any reasonable amount of 
standing and walking can be clone from the first as soon as this is applied. 
It is the only form of apparatus we use now, and it very seldom fails if 

properly applied. In some cases it may be 
necessary to break down the adhesions first, 
but in children this is rare. It is, however, 
important that the foot be moulded into good 
shape each night and morning. 

Standing and walking on tiptoe, dancing, 
and friction are all useful supplementary 
means, as pointed out by Ellis, who is of 
opinion that the flexor longus pollicis is a 
very important factor in tying together the 
pillars of the arch of the foot (' Lancet/ 
February 9, 1884). 

No operation is ever required for acquired 
flat-foot in children. 

A form of distortion in which there is ad- 
duction of the foot, or rather rotation inwards, 
in which the deformity depends upon a rota- 
tion of the whole leg, is sometimes met with. 
It gives rise to the condition popularly known 
as ' duck-toes.' The unsightly gait may be- 
due to congenital malposition or to rickets ; 
it has been proposed to call the deformity 
'club-leg,' and to remedy it by osteotomy of 
the femur {vide supra, chapter on RICKETY 
Deformities ; also Parker, ' British Medi- 
cal Journal,' Oct. 27, 1888). 

Wry-neck or Torticollis is a fairly 
common affection in childhood, and may be 
due to any of the following conditions : 

1. It may be congenital, probably due to 

malposition in utero — sometimes to mal- 

development, as in a case of our own, in 

which wry-neck, deficient development of the 

external ear, mastoid region, and lower jaw 

co-existed with cleft palate and mental 

deficiency. 1 

2. It may result from injuries at birth, lacerations of muscles, &c. Volk- 

mann has found the sterno-mastoid represented by a band of cicatricial 

tissue. Sterno-mastoid tumour (p. 24) is sometimes followed by torticollis, 

the injured muscle subsequently becoming contracted. We have had several 

cases in which there was a history of sterno-mastoid tumour in infancy. 

1 Intercalations of more or less developed vertebral bodies may produce wry-neck of 

one kind, as it may lateral curvature. 




Fig. 



:8c— Shows an 'Artificial Muscle' 
applied for Flat-foot. 



Wry -neck 741 

(See D'Arcy Power, ' Med. Chir. Trans.' vol. lxxvi. 1894.) Petersen, however, 
thinks the haematoma is a result of injury to the previously shortened muscle. 

3. It may be spasmodic, due to central or peripheral nerve lesions or 
reflex irritation. 

4. It may result. from suppuration in the neck, due to either glandular 
abscesses or cervical caries, causing matting together of the parts and con- 
tracture of the muscles. 

5. Burns or other injuries may, of course, produce cicatricial torticollis. 
In its most simple form wry-neck is due to contraction limited to one 

sterno-mastoid, which is felt as a hard tight cord in the neck ; the head in 
such cases is drawn towards the shoul- 
der, and the face turned towards the 
opposite side (fig. 181). 

Golding Bird x is inclined to con- 
sider the condition due to a cerebral 
lesion analogous to the cord lesions in 
infantile paralysis. 

In other instances the sterno- 
mastoid is not alone affected, but the 
scalenes, trapezius, and cervical fascia 
contribute to the deformity. 

Treatment. — In slight cases in quite 
young children regular daily stretch- 
ing and manipulation of the rigid 
muscles may suffice to get rid of the 
deformity. In the severer forms of the 
affection tenotomy is the only effectual 
treatment. The sterno-mastoid, and 
sometimes the trapezius, require divi- 
sion. For tenotomy of the sterno- 
mastoid the knife is passed through 
the interval between the two heads, and 
its edge turned forward against each in 
succession, the child's head being 
held stretched by an assistant. Care 
must, of course, be taken not to wound the anterior jugular vein at the front 
edge of the muscle, or the external jugular at the posterior border, nor to 
carry the knife so deeply as to endanger the carotid sheath. We usually 
divide the muscle through an open incision, and where the cervical fascia is 
also tightly contracted it is necessary to divide it, and in such cases it is 
certainly safer to make an incision over the muscle and gradually dissect 
through the rigid parts in an open wound. Some surgeons prefer to divide 
the muscle at its middle. Two days after the tenotomy the apparatus 
(fig. 182) recommended by Mr. Southam should be applied. The following 
case is characteristic : 

Case. — Torticollis. — John Wm. G. , age 5 years ; admitted August 5, 1885. A neurotic 
family history ; the child has never been strong ; the deformity is congenital, but has bean 




Congenital Wry-neck. 



Guys Reports, 



vide also Murray, Liverpool Med. Chir. Jour. Juby 



742 



Club-foot^ Deformities of Limbs, dfc. 



getting worse lately, and is increased when the child is not well ; has lately had toothache 
on the left side. On admission the left sterno-mastoid is contracted in its whole extent, 
forming a firm prominent band; the interval between the tendons is deeply marked, the 
sternal tendon being the most prominent. The chin is rotated clinch from the middle 
line downwards and to the right ; the platysma is also prominent. August 13, tenotomy 
of both heads through the interval ; the cervical fascia was also partially divided. Anti- 
septic operation and wood-wool dressing. 14th, no pain ; the head was packed in sand- 
bags. 17th, a plaster-of- Paris jacket was put on with hooks fixed in it, and a rubber 
muscle was applied parallel to the right sterno-mastoid, attached to the head by circular- 
bands of strapping. 20th, another 
muscle was applied in a corresponding 
position at the back. 22nd, made out- 
patient. He was seen subsequently, 
and hardly any visible deformity re- 
mained. November 10, 1885, quite 
well. 

Spasmodic torticollis, if it does 
not yield to medical treatment, 
may require stretching or resec- 
tion of the spinal accessory nerve 
— all causes of reflex irritation, 
carious teeth, worms, otorrhcea, 
enlarged glands, &c, having been 
previously removed. 

The other forms of wry-neck 
require treatment on general 
principles, or are irremediable ; 
special care must, of course, be 
taken not to overlook the presence 
of cervical caries. 

In all cases of wry-neck, where 
manipulation is admissible, steady 
and regular attempts should be 
made to remedy the distortion ; 
friction and steady stretching of 
the neck with the hands should 
be tried, and the child made to practise, before a looking-glass, .trying to 
hold the head straight. To supplement these means, various apparatus, 
collars, &c, may be used ; the one we have found most efficient is that figured 
for use after tenotomy. In quite young children, of course, no voluntary 
help from the child can be obtained, but the friends must be instructed what 
to do, and in older patients it is a good plan, as Mr. Roth has pointed out, 
to get the child familiar with the exercises before the tenotomy is performed, 
so that no time may be wasted afterwards. 

Congenital cases, where the sterno-mastoid alone is involved, are usually 
completely curable ; many of the spasmodic cases get well either sponta- 
neously or after removal of some source of irritation. In cases where 
the scaleni are involved there is more difficulty, and section of cervical 
nerves or [of these muscles may be desirable, provided a suitable case 
occur. In many of these patients the face is undeveloped, or distorted 




Fig 



— Artificial Muscle applied for Wry-neck 
after division of the Sterno-mastoid. A Sayre's 
jacket is applied to the trunk, and traction made 
from a poroplastic cap or ring of strapping. 



PLATE II. 




Skiagram of the arm and chest wall in a case of Myositis ossificans, 
showing the bony spines and plates in the muscles. 



Congenital Deficiencies of Muscles — Tenosynovitis 743 

on the affected side ; secondary lateral curvature of the spine may also 
result. 

It is certain that the condition already described as sterno-mastoid 
tumour sometimes leads to subsequent development of torticollis from cica- 
tricial contracture of the muscle ; in the many cases we have seen, such 
result has followed in several instances, and D'Arcy Power has collected a 
number of other cases. Op. cit. 

No treatment is required for the sterno-mastoid tumour except that watch 
should be kept for the slightest sign of onset of the torticollis, and suitable 
preventive exercises employed. 

Congenital Deficiencies and Malformations of Muscles are often 
slight, and interesting from an anatomical rather than a surgical point of 
view ; in other instances, such as those where the pectoral muscles are absent, 
in association with arrest of development of the chest-wall, the malformations 
are irremediable ; in others, again, some help may be obtained by elastic 
cords ('artificial muscles'), or possibly by the transplantation of muscle 
flaps ; for the most part, however, these conditions are beyond the present 
reach of surgery. 

We must just mention the very rare condition known as myositis ossifica?is^ 
of which a remarkable instance was lately under our care. The patient was 
a child of six years old ; the affection began about a year before and was 
steadily progressing ; cervical, pectoral, brachial, abdominal, intercostal, and 
femoral muscles were many of them more or less affected, without any 
disturbance of health so far. Xo cause is known for the disease, and no 
treatment seems to be of any avail ; the subjects of it usually die from 
interference with the respiratory movements or some intercurrent illness, 
though they may live for years (Plate II.). 

Tenosynovitis is an affection common in, but by no means peculiar to, 
childhood. Tuberculous tenosynovitis is, however, not rare, usually as a 
secondary condition to joint disease, but occasionally occurring alone ; its 
existence is to be suspected when swelling and suppuration occur in the 
course of a tendon in a tuberculous subject, and its treatment must be on 
general principles — rest and constitutional measures in early stages, and 
careful scraping out in the severer ones. We have once or twice seen sup- 
puration in the large palmar sheath, and in one instance it occurred in a 
premature child only a few weeks old, coming on without assignable cause ; 
secondary pyaemic abscesses elsewhere followed, but the child ultimately 
got quite well. 

Bur see in children are not usually very well developed. Patellar bursitis 
is, however, not very rare, and we have seen it lead to disease of the knee- 
joint ; the olecranon bursa is also occasionally enlarged, while effusion into 
the semi-membranosus bursa is not uncommon. Ganglion is most common 
in the radial extensor tendons and in those of the thumb ; in recent cases the 
fluid may be dispersed by pressure, in others it should be punctured with a 
grooved needle and the clear gelatinous contents let out ; a pad with firm 
pressure should be kept on for three weeks afterwards, or the sac is likely to 
refill. In obstinate cases the sac should be laid open and as much of it as 
possible dissected away. 

Malformations. — Other congenital malformations may be conveniently 



744 Club-foot. Deformities of Limbs, &c. 

considered as (i) those due to errors of growth in the embryo itself — in- 
herent errors ' — and (2) those due to abnormal intra-uterine surroundings- 
acquired errors ; or they may be classified as deformities by excess, deformi- 
ties by deficiency, and deformities by distortion. In either case it is some- 
what difficult to assign to their proper place all the malformations met with, 
and fortunately it is of little practical importance, as far as treatment goes, 
that we should do so. 

Among inherent errors may be classed supernumerary fingers and toes— 
polydactylism ; some cases of webbed fingers and toes— syndactylism ; tri- 
podism ; congenital tumours of the dermoid class — with which might be put 
the cases of so-called fcetalinclusion. Possibly certain less-marked malfor- 
mations, such as those affecting only some of the structures of a limb, con- 
genital varices, venous and lymphatic, congenital muscular abnormalities, 
&c, should be placed here, though these, in so far as they are of surgical 
importance, are more conveniently considered under the organs to which 
they belong. Many instances of inherent errors are better seen in the head 
and trunk, such as a failure of closure of the dorsal and ventral laminae and 
of the visceral arches of the head, meningocele, spina bifida, harelip, extro- 
version of the bladder, &c. 

Among acquired errors are all those due to intra-uterine pressure, either 
by the walls of the uterus itself, by amniotic bands (Gurlt), 2 by pressure or 
violence applied to the uterus from without, or by mere malposition of the 
foetus in utero, at whatever period of gestation they arise. 

In considering what malformations should be placed in this group, we 
must remember that it is probable that pressure or violence acting in a very 
early stage of development leaves much less obvious signs of injury than if 
it is inflicted at a later period ; thus constriction or pressure during the later 
months of pregnancy may leave distinct cicatrices, while the same forces 
applied earlier may cause deficiencies without any marks of violence or 
scars. 3 

In this group will be placed deficiency of limbs, fingers, &c. (intra-uterine 
amputation), as examples of the highest degree of deformity ; also congenital 
constrictions and dimples, together with congenital synostoses or deficiencies 
of parts or the whole of a limb, such as absence of one or more of the carpal 
or tarsal bones, 4 of the lower end of the radius or ulna, causing club-hand ; 
or mere faults of position such as are found in club-foot, flexed or hyper- 
extended joints, &c. 

The proof that some of these deformities are the result of errors of the 
embryo, and others of abnormalities of the environment (intra-uterine 
pressure, &c), is in many cases easy, in others impossible. Thus polydac- 
tylism and congenital tumours cannot be the result of intra-uterine pressure, 

1 ' Vices of conformation.' 

2 Or, as Montgomery has pointed out, by bands of lymph stretching from one part 
of the foetus to another ; cf. Intra-uterine Amputation, p. 746, and vide Todd's Encyclo- 
pedia. 

5 Vide Med. Chir. Trans. 1877 for a case of complete absence of both upper limbs 
without any scar ; this was supposed not to be due to amputation. 

4 Bryant {Diseases of Children) records a case of congenital absence of the fibula, os 
calcis, cuboid, and three outer toes ; and this is not a very rare malformation. 



Intra-uterine Amputation 745 

while congenital deficiency of limbs is shown to be at least sometimes due to 
constriction by the fact that the amputated limb has been found lying loose 
in utero, and in other instances the limb has been found incompletely 
severed, or even an unhealed stump has been present. On the other hand, 
the absence of the amputated limb, and the smooth scarless appearance of 
the stump sometimes met with, may be explained by the fact that the limb 
may become disintegrated by maceration in utero, and if the separation 
took place at a very early stage the scar might disappear during growth or 
become indistinguishable from its small size. Pressure, again, might well 
produce entire arrest of growth of a limb without amputation, and thus 
no scar would be left, while in other cases pressure might produce fusion of 
parts together, as in web fingers. 1 Evidence in favour of this is afforded by 
the co-existence of amputations with webbed fingers (both, in such cases, the 
result of pressure, though even here the webbed condition may have been 
due to mere retarded development from constriction). 

Case. — Web Fingers and Toes, fb*c. — Albert B. , age 9 months ; admitted November 2, 
1885. No history of deformity or maternal impression. Left hand, second and third 
fingers are united as far as the first interphalangeal joint ; there is no nail on the first finger, 
a very imperfect nail on the second. Right hand, the first finger has a deep constriction 
around the last phalanx, with a bulbous enlargement of the end of the finger ; the second 
finger has a similar constriction, but the part beyond is small and almost without nail. 
There is a very deep constriction round the right leg, about one inch above the ankle, 
almost reaching to the bone. The child can stand on the leg and moves the foot freely. 
Left foot, there is only one phalanx in the great toe, and no nail ; the nail of the second 
toe is very rudimentary, and there is a small outgrowth on the fourth toe. Right foot, 
toes perfect, but the foot is hypertrophied and flat. November 5, Didot's operation on 
the hand. 7th, healing well. 12th, stitches removed ; flaps have united largely, but there 
is some granulating surface. Sent home on November 13. The flaps subsequently gave 
way partially, but were again nearly healed, when the child died at home of broncho- 
pneumonia. 

Suppression of an intermediate segment of a limb, as where fingers are 
found springing from a stump of the upper arm, is probably due to pressure. 

Again, inherent and acquired errors may co-exist, and would be likely to 
do so. A local overgrowth of the embryo might well disturb the relation 
between the uterus and its contents, and lead to deformity by pressure.' 2 

Lastly, reversion, atavism, and so on, must not be left out of sight in 
considering these questions, which cannot, however, be further discussed 
here. 3 

Whether double monsters, dermoid cysts of the ovary and testis, and 
congenital tumours of various kinds are the result of fcetal inclusion, partheno- 
genesis, or gemmation, is a question that cannot be entered upon here ; it 
will be sufficient to say that some cases are certainly the result of 'fused' 4 

1 Web fingers are, however, no doubt in most cases due to mere persistence of the 
fcetal spade-like condition of the hands. 

2 Deficient development of one half of the body, with facial paralysis, has been met 
with (Barker, Clin. Soc. Trans. 1884). 

3 Vide Bland Sutton's Lecture, Lancet, 1887-8 ; also Ballantyne's Antenatal 
Pathology. 

4 'If during development the medullar}* fold remains cleft, two complete foetuses are 
formed from a single ovum,' and every degree of combination from twins to very rudimen- 
tary ' parasitic' foetuses may result. (Bland Sutton, Lancet, February n, 1888.) 



746 



Club-foot, Deformities of Limbs, &e. 



embryos — e.g. double monsters, adherent twins, and so on — while some con- 
genital tumours are equally certainly mere errors in the closing in of the 
folds of the blastoderm or of the local involutions by which certain organs 
are formed. 1 We have recently had a remarkable case of abdominal tumour 
in a child three months old which proved to be an included foetus lying in 
the lesser cavity of the peritoneum. 

Supernumerary dig-its are found attached in various ways ; thus, a mere 
little fleshy outgrowth with or without a nail, and with no bony support, may 
be attached to a more or less normal finger, or the end of a finger may be 
bifid, with two nails. In other instances a supernumerary thumb with two 
phalanges may spring from the joint between the 'metacarpal ' bone and the 
first phalanx, a common joint existing for the two thumbs, or the extra one 
may be attached to the side of the proper one. It is sometimes not easy to 
make out which is the supernumerary and which the natural digit ; in such 
cases the most useful one should, of course, be left. 

In any case of supernumerary fingers the additional one should be 
removed in infancy, so as to allow the other as far as possible to be trained 




fU^J 




Fig. 183. — Double Thumb. 



Fig. 184. — Intra-uterine Amputation of Fingers. 



into its proper position. Where a joint is common to the two fingers care 
must be taken not to injure the articulation nor to allow it to suppurate, for 
fear of a stiff joint resulting. Supernumerary toes should be removed if 
they cause distortion of the foot or are likely to lead to trouble in wearing 
ordinary boots. 

For figures and details of the different forms of polydactylism we must 
refer to Annandale's work on ' Diseases of the Fingers and Toes.' 

Occasionally cases are met with where more or less of a limb is deficient, 
and the member ends in a pointed or truncated extremity like an amputation 
stump ; this may occur at any point in the length of a limb. Sometimes 
only parts of one or more digits are deficient, sometimes the amputation has 
been incomplete, and a deep sulcus round the finger or limb, with often a 
bulbous expansion on the distal side of it, marks the seat of pressure. This 
constriction in some cases is so tight that there appears to be little left 
undivided except the bone, and this condition we have met with associated 



1 Numerous figures and references wi 
Menschen. 



be found in Forster's Missbildungen des 




Skiagram of a case of Club Hand, with arrest of development of the 
radial (pra^axial) border of the limb. 



Club-hand 



747 



with talipes ; the movements of the limbs were, however, good, and 
evidently the deeper structures, though compressed, were not divided. We 
have also seen these constrictions associated with dimpled depressions over 
the knees and shoulders, and rigidity of the joints, also the result of intra- 
uterine pressure ; in one instance there was also microcephalus. Most of 
the cases of intra-uterine amputations, and of these constrictions, are the 
result of pressure by amniotic bands or fcetal adhesions, as already pointed 
out ; but it is undoubtedly occasionally true that pressure by the umbilical 
cord, so gradually exerted as not to interfere with its own circulation, may 
produce the same effect. 1 We have not seen a case of constriction 

requiring any operation, though it has 
been suggested by Mr. Edmund Owen 
to pare the adjacent surfaces and unite 
them so as to obliterate the groove. 





Fig. 185. — Congenital Arrest of Develop- 
ment of one Lower Limb. 



Fig. 186.—' Club-hand,' so called. There is 
absence of the radius and thumb with ab- 
duction of the hand. 

Nothing, of course, can be done 
for congenital amputation except the 
use of prothetic appliances, and it is 
wonderful what use these patients can 
make of their stumps. As already 
pointed out, in some instances there is a 
distinct scar, in others a smooth unbroken cutaneous surface, and sometimes 
rudimentary digits remain attached to the end of a stump containing only 
the humerus or femur ; this is rather an arrest of growth by pressure than a 
true amputation. So, too, sometimes the femur or humerus is congenitally 
very short or deficient. (Fig. 185.) 

Club-band, so called, is a somewhat rare affection, resulting from arrest 
of development of more or less of the radius or ulna, with consequent 
abduction or adduction of the hand (Plate III.). It is not in any sense 
really comparable to the ordinary forms of club-foot, and is little amenable to 
treatment. Something, however, may be done by manipulation to remedy 
the deformity and possibly encourage growth of the shortened bone by 
friction and removal of pressure. Less often the hand is fixed in flexion or 
1 Vide Neville, Brit. Med. Jour. 1883, p. 209. 



7 4 3 



Club-foot, Deformities oj Limbs, frc, 





hyper-extension, and in these cases sometimes tenotomy may be required. 
Similar deformities may, of course, result from cicatricial contraction after 
injury. In one instance the radius was entirely deficient on both sides, and 
the ulna was fractured and repaired, probably i?i utcro. At the suggestion 
of one of our Resident Medical Officers, Mr. J. H. Thompson, we trans- 
planted some bone from another child into an incision between the muscles 
of the forearm. The wound healed perfectly, and the bone was growing at 
the time of the child's death from an independent cause two or three weeks 
later ; the position of the hand was much improved. Careful bandaging 
and the use of splints will do good in some cases if treatment is begun early. 
Web Fingers. — Various degrees of this deformity are met with : thus 
there may be a mere extension of the normal web forwards to the first inter- 

phalangeal joint. In other in- 
stances metacarpal bones and 
phalanges may be fused to- 
gether, or bound in very close 
contact throughout the whole 
length of the digit : occasion- 
ally the union is only at the 
distal ends ' (vide antea). The 
deformity is usually more or 
less perfectly symmetrical, and 
often associated with a similar 
condition in the feet or with 
some other deformity. 

Where there is complete 
bony fusion of two adjacent 
digits no attempt should be 
made to separate them ; where, 
however, only skin and sub- 
cutaneous tissue unite the two 
fingers, they should be sepa- 
rated. Simple division of the 
web is of little use, since the 
wound granulates up from the bottom and more or less reunion occurs. 

Several plans have been devised to meet this difficulty, such as applying 
an elastic cord between the fingers and fastening it round the wrist after 
division of the web ; perforating the base of the web and putting a thread or 
wire through the orifice and allowing it to heal, and then dividing the web. 
Another mode consists in dividing the web and then bringing a flap of skin 
from the dorsum or palm across between the fingers so as to interpose a 
bridge of skin at the base (Norton). The best plans are the last-mentioned 
and that advocated by Didot, in which a dorsal flap from one finger and the 
web, and a palmar flap from the other finger and the palmar aspect of the 
web, are cut ; the rest of the web is then divided, and the flaps are wrapped 
round the raw surface of the finger to which they remain attached. In 




-Double Club-hand. 



1 This could hardly be the result of failure of the natural differentiation of the finger: 
in foetal life, which results from the phalanges outgrowing the webs. 



Congenital Rigidity of Joints 



749 



doing this operation, however, it will be found that there is not sufficient 
skin to cover both fingers, and one has to heal by granulation. Web toes 
do not require treatment. 

Congenital Rigidity of Joints and Contractions. — As already stated, 
children are sometimes born with joints, chiefly the knees, elbows, and 
shoulders, which are stiff, or, on the other hand, unduly lax ; and sometimes 
these joints are fixed in flexion, sometimes hyper-extended, or at least hyper- 
extensible! In such cases there are not rarely marks of pressure about the 
joints — depressions and adhesions 
of the skin. Probably the condi- 
tions determining such deformities 
are like those causing talipes, viz. 
intra- uterine pressure or malposi- 
tion ; thus the £ genu recurvatum ; 
sometimes seen results from the 
limbs being packed in hyper- 
extension along the ventral surface 
of the body (figs. 188, 189) ; it is 
sometimes described as congenital 
dislocation of the knee. In these 
patients the patella is usually either 
absent or very small ; it, however, 
develops as the position and mo- 
bility of the knee are improved by 
treatment. The rigidity and hyper- 
extension of the joint may be 
almost perfectly overcome by suit- 
able exercises and apparatus. 
Failure of developmental rotation 
accounts for other deformities. 

Diligent friction and passive 
movement, together with the appli- 
cation of splints, as the individual 
deformity may require, will some- 
times effect great improvement ; * 
in other instances little success 
attends treatment. 

One or more of the fingers or 
toes may be congenitally contracted 
either in flexion or extension : the 
contraction, often slight at first, 
tends to increase as the child grows, 
tion. In most instances it has been shown that contraction of the ligaments 
of the inter-phalangeal joints is the cause of the deformity. 

We have met with a non-congenital form of contraction of the terminal 




. 188. Genu recurvatum and Talipas calcaneus 
from sketch bv the late Mr. C. F. Sutton. 



Hammer-toe is a result of this condi- 



1 Berkeley Hill records a good case in which there was so much rotation that the heels 
looked directly forwards. By the use of apparatus and tenotomy an almost perfect result 
was obtained.—/?;-//. Med. Jour. July 12, 1884 ; vide also 1883. ' 



75o 



Club-foot, Deformities of Limbs, &c. 



joints of the index and middle fingers. The skin and fascia were the structures 
affected, just as in Dupuytren's contraction. According to Adams, the little 
finger is more often affected, and the deformity is said to be markedly 
hereditary, and to be commomy associated with a history of 'hammer- 
toe.' ' 

Stretching and simple splints, in ordinary cases, is the treatment required. 
If neglected, troublesome corns or bunions and distortion of the nails may 

result from pressure of 
boots. Division of the 
lateral ligaments, or in some 
cases resection of a joint or 
part of the shaft of a pha- 
lanx, or even amputation, 
may be the best treatment 
for hammer-toe. 

' Hallux flexus,' first 
described by Mr. Davies 
Colley, is defined as a 
' progressive diminution in 
the normal range of exten- 
sion of the great toe.' It 
causes lameness, is patho- 
logically closely allied to 
hammer-toe, and requires 
treatment by rest followed 
by manipulation and fric- 
tion, and in severe cases by 
division of the lateral liga- 
ments or osteotomy. Vide 
also ' Metatarsalgia,' p. 
739. Hallux valgus and 
other deviations of the toes 
are rarely serious in chil- 
dren, and are usually amen- 
able to treatment by splints, 
or wearing of boots and socks with stalls for the toes. So-called 'toe-post 7 
boots are very useful for these cases. 

It must be remembered that some of these patients with distorted limbs 
are cases of cerebral deficiency, and for them of course little can be done. 

Congenital Dislocations, so called, of almost any joint may be met with : 
thus the temporo-maxillary, elbow, and wrist joints, the joints of the spine, toes, 
&c., have been found displaced, though such deformities are by far most fre- 
quently met with in the hip. These conditions have been variously explained : 
injury in utero or at birth, intra-uterine inflammations, convulsions, pressure, 
nervous, bony, and muscular lesions have all been assigned, as in club-foot, as 
causes of congenital dislocations. It is most probable that, as in club-foot, 




Fig. 189. — Abnormal position in utero, causing genu recur- 
vatum and talipes calcaneus, &c, from sketch by the late 
Mr. C. F. Sutton. 



1 Adams, Lancet, December 13, 1890, also li 
August 1891. 



11 ; and Anderson's Lectures, Lancet, 



PLATE IV. 




Congenital Dislocation ' of the hip. The acetabulum is seen far below 
the head of the femur. 



Congenital Dislocation of the Hip 



751 



intra-uterine pressure from malposition is the most frequent cause, though 
not the only one. In all cases more or less deformity of the bony articular 
surfaces is found, and this is of the utmost importance, since it largely pre- 
vents the possibility of anything like complete reduction. 

In 'congenital dislocation' of the lower jaw the condyle and glenoid 
cavity, as well as much of the bony framework of that side of the skull, have 
been found stunted. Occipito-atlantoid dislocation, both backward and 
forward, has been described ; in the former the head is flexed, in the latter 
hyper-extended. 

Dislocations of the clavicle in the varieties , 

met with in later life are also mentioned by 
Guerin. 

The humerus may be displaced down- 
wards, forwards (subcoracoid), or backwards 
(subspinous), with arrest of growth of muscle 
and bone, and deviation from the normal 
shape of the articular surfaces. 1 Displace- 
ments of the elbow and wrist have also been 
met with. 2 The most important of all these 
malformations is Congenital Dislocation 
of the Hip, since it is by far the most fre- 
quent, and sometimes seriously incapacitates 
the subject of it. In these cases the ace- 
tabulum is small, shallow, and may be filled 
with fat or ' webbed over ; ' the head of the 
femur may be nearly normal or much stunted. 
A more or less perfect capsule may be 
present, and this may be thickened ; or, 
again, a sort of interosseous ligament may 
exist : the ligamentum teres is atrophied, 
the muscles around the joint are wasted. 
The affection may be unilateral or more often 
bilateral. The femur is usually freely movable 
and slides up and down upon the dorsum ilii 
to an extent of sometimes two inches or 
more (Plates IV., V.). 

The affected limb or limbs are usually 
imperfectly developed throughout. There is 
always a good deal of lameness in severe cases, though we have met with 
slight degrees of this deformity in which the joint was not very much 
altered. There are marked lordosis and a peculiar 'waddling 5 way of 
walking which is very characteristic. Usually the displacement is upwards 
and backwards, but it may be in almost any direction ; the limbs are 
sometimes adducted markedly. 




Fig. 190. — i'Congenital Dislocation 
ofbothHps. Not a severe case. , 



1 Dislocation of the humerus appears to be often associated with other conditions of 
malformation ; in a case shown us by our friend Mr. C. E. Richmond there were sub- 
spinous dislocation of the shoulder and dislocation of both hips. See Chapter on Injuries. 

2 See Hamilton's work on Fractures and Dislocations. 



752 Club-foot, Deformities of Limbs, &c. 

Besides the ungaihliness of the walk, it is possible that the deformity of 
the pelvis may, as Adams suggested, be important from an obstetric point ot 
view. There is little to be done for these cases, though it has been recom- 
mended that the affected limb should be supported and fixed in a state of 
extension, and it is said that a certain amount of increased stability in the 
joint may result. 1 Section of the muscles surrounding the joint, and even 
excision, as well as scarification of the deeper tissues and hollowing out the 
surface of the ilium, have been practised with the object of giving increased 
stability to the joint, but it is unlikely that any of these plans will gain favour. 
Hoffa's mode of operating has been tried in a number of cases, but published 
results do not encourage further attempts in this direction. Prolonged ex- 
tension in bed we have found do harm rather than good, though some 
successful cases have been recorded. When the affection is unilateral a 
thick-soled boot on the short limb will improve the gait, and in some cases 
a pelvic girdle, with pads to support and fix the end of the femur, has been of 
service. Long walks and long standing should be avoided, but we cannot 
recommend any operative treatment. The history of the case, the absence of 
pain and rigidity, and the peculiar gait distinguish the affection from hi}) 
disease. Rickety lordosis sometimes closely resembles congenital dislocation, 
but careful examination of the relative positions of the trochanters and iliac 
spines will prevent a mistake. The affection is by no means rare. [See 
also Coxa Vara, p. 211]. The various operative methods of treating this 
condition, though much recommended by their inventors, have failed to 
prove themselves justifiable. The bloodless methods, such as reduction 
(Paci) by manipulation, are, though harmless, little more successful. It is 
probable that most of the successful cases have been instances of traumatic 
dislocation at or after birth, and not of developmental deficiency. 

So-called Congenital Dislocation of the Knee has been already men- 
tioned as ' genu recurvatum ; ' this joint is also occasionally found with partial 
backward or lateral displacement. If seen in quite early infancy, these de- 
formities are fairly amenable to treatment by manipulation and splints, and 
we have been able to completely remedy the deformity of ' recurved knee' 
by these means {vide figs. 188, 189). 

Besides the deformities already described, it is necessary just to men- 
tion the occurrence of cases of Congenital Fissure of the Sternum from 
non-union of the different centres of ossification, or rather non-closure of the 
ventral laminae, sometimes associated with ectopia cordis. Cases of deficiency 
of the ribs over a larger or smaller area, and lack of development of the 
muscles of the chest-wall and of the mammary glands, may be met with ; we 
have seen hernia of the lung through a gap of this sort. ( Vide Thompson, 
' Teratologia,' January 1895.) 

Congenital Deficiency of one or both Clavicles or of the Scapula 
may also be occasionally seen. A suprascapulahas been met with, attaching 
the scapula to the vertebrae, and requiring removal (Willetf and Walsham, 
' Med. Chir. Trans.' 1883). Deficiency or imperfect development of the patella 

1 Mr. Adams, Brit. Med. Jour. February 1890, relates cases illustrating the value of 
prolonged extension, and figures appliances. Vide also Lovett on Disease of the Hip, 
Boston, 1892, and papers in the Annals of Surgery, 1895. Also Tubby On Deformities, Sfc, 



PLATE V. 




'Congenital Dislocation' of the hip, the fellow to Plate IV. 



Deformities of Limbs, &c. 753 

sometimes occurs ; it is usually absent in cases of genu recurvatum. Many 
other normal conditions may occur — some deficiencies, some excesses, as 
in the common cases of supernumerary mammae, which are doubtless instances 
of reversion, and so on : but these cannot be discussed here. Many require 
no treatment ; others must be dealt with on general rules. Occasionally pro- 
tective shields may be required for such cases as thoracic hernia. The 
works of Ballantyne and Tubby should be consulted for recent accounts of 
these malformations, as well as papers by many American surgeons in the 
' Annals of Surgery,' and elsewhere. 



754 Diseases of the Nose 



CHAPTER XXXIV 

DISEASES OF THE NOSE 

The orifices of the anterior nares are a favourite seat of eczema, lupus, and 
superficial tuberculous ulceration ; other cutaneous affections and nawi are 
also often met with upon the surface of the nose : vide Chapters XXXYIII 
and XIX. 

The nasal cavities in children are exceedingly often the seat of acute or 
chronic catarrh, the result of cold, or extension from the pharynx. Catarrh 
also commonly occurs in rickety, tuberculous, or syphilitic children. 

Acute Catarrh is generally simply mucous ; it may, however, become 
purulent, or may be so from the first, especially if it is the result of inocula- 
tion, which may occur at birth or accidentally at a later period. 

Chronic Nasal Catarrh is marked by discharge of muco-purulent material 
from the nose, swelling of the mucous membrane and of the skin of the 
anterior nares, with often some thickening of the upper lip from irritation ; 
the voice is nasal, respiration is impeded, deafness is often present, the 
child snores, and in an infant, suckling is often difficult, sometimes impossible, 
from obstruction to breathing through the nose. Occasionally the inflam- 
mation extends to the antrum, nasal duct, or frontal sinuses. On examin- 
ing the nose the interior is seen to be red and angry-looking, often slightly 
excoriated ; it easily bleeds, and there are frequently dried scabs on its surface, 
while stringy mucus is apt to collect upon the lips in neglected children and 
give rise to soreness. Where one nostril alone is affected, careful search 
must be made for one of three conditions : a foreign body, such as a button, 
a bit of slate pencil, or a date-stone, &c. ; a mucous polypus growing from the 
region of the inferior or middle turbinated bone — a somewhat rare condition 
in childhood ; or, thirdly, a deviated nasal septum. 

Chronic catarrh, from whatever cause, is apt, if neglected, to give rise to 
ozaena from decomposition of the retained secretion, or from caries or 
necrosis of the bones of the fossae ; where the bones are involved the fcetor 
is more intense than in other cases. 

Should the inflammation extend to the cartilaginous and bony septum, 
the nose may lose its support, by softening of these structures, and become 
flattened and depressed. Where the outer walls are more especially 
attacked, a broad thickened nose results. In most cases these deformities 
occur in connection with congenital syphilis rather than in tubercular or 
simple bone lesions. A probe will usually detect the presence of bare bone, 
and it must be remembered that in cases of apparently simple polypi a 



Chronic Nasal Catarrh 7$$ 

patch of exposed bone will often be felt. Bleeding from the nose in these 
affections occurs often in small amounts, but rarely to any serious extent. 

Diagnosis. — The existence of chronic nasal catarrh is obvious ; its cause 
requires looking for, and this should be done systematically. First, if 
unilateral, the causes already mentioned — foreign body, deviated septum, 
or polypus — are to be suspected. If double, the throat should be examined 
for enlarged tonsils, chronic pharyngitis, and post-nasal adenoid growths. 
Evidence of congenital syphilis or tuberculosis may be obtained, or some- 
times simply carious teeth or eczema may be the source of the trouble. 

Treatment. — If the cause is local, an anaesthetic should be given, and the 
foreign body, post-nasal growths, &c, removed. To remove a foreign body 
from the nose, a simple loop of silver wire is useful, or a pair of dressing 
forceps or a small scoop may be employed ; sometimes a finger passed from 
the mouth into the posterior nares is of service, and occasionally the simplest 
plan is to push the foreign body.backwards into the pharynx and remove it from 
the mouth. In one of our cases the body, a button, escaped into the pharynx 
while the child was under chloroform, and was found in the vomit brought 
up by the child on its awaking. In syphilitic and tuberculous cases syringing 
out with warm alkaline lotions (sodii bicarb, gr. xx ; aq. §j), or in older 
children the nasal douche, is the most efficient means of clearing away the 
crusts ; this should be done three or four times daily, and subsequently 
powdered boric acid or tannic acid and iodoform in equal parts should be 
blown into the nose through a quill or insufflator, or the nasal cavity may 
be brushed over with glycerine of tannin or lead lotion. Sometimes a spray 
may be substituted for the syringing after the nose is once cleared. Solution 
of hydrochlorate of cocaine, 5 to 10 per cent., may be used as a spray or 
brushed on, either before removing a foreign body or in cases of acute catarrh. 
Cleanliness and care of the general health, with mercury or iodide of potassium, 
or both together, according to the child's age, are required in syphilitic cases. 1 
Any sequestra should be removed as early as possible, and all foul crusts 
kept constantly cleared away. Cod-liver oil and iron, with the usual hygienic 
measures and careful cleansing of the nose, together with iodoform insuffla- 
tion, is the best treatment for the tuberculous cases. Nitrate of silver, gr. 
x-xxx to 3j, is sometimes used with advantage as an occasional application. 
In nearly all chronic cases the prognosis is somewhat uncertain, and the 
course of the disease tedious. Where the above-mentioned methods fail, and 
especially in tuberculous ulceration of the nasal mucous membrane, an 
anaesthetic should be given and the affected parts well scraped with a 
Yolkmann's spoon, or cauterised with the wire cautery. 

Nasal obstructio7i, apart from the causes just mentioned and those 
already described under Diseases of Tonsils, &c, may be due to deviation of 
the cartilaginous septum. This is sometimes congenital — more often it is the 
result of fracture of the septum, or dislocation from either the ethmoid or 
vomer, or from the nasal spine of the upper jaw ; or, again, it may be the 
result of a chronic perichondritis, following an injury, and resulting in soften- 
ing and subsequent deviation of a local patch of the septum. If the whole 

1 In infants mercury alone, in children over three or four years iodide of potassium 
alone, or, failing a good result, combined with mercury, is, we find, the most successful 
plan. 

3C2 



y$6 Diseases of the Nose 

cartilage is involved, there will be some flattening of the end of the nose ; 
this, however, does not usually occur. Simple chronic perichondritis, causing 
thickening, hematoma of the septum, or abscess, or even ecchondrosis 
of the cartilage may also be met with. The treatment of deviated septum 
consists in forcible straightening with a pair of guarded sequestrum forceps 
or with Adams's special instrument ; and the subsequent wearing of a nasal 
plug, such as Walsham's or the one devised by one of the present writers, or, 
best of all, a piece of rubber drainage tube, is required. In some cases 
removal of the projecting mass is called for : in such circumstances the 
muco-perichondrium should be dissected up and laid down again after 
removal of the cartilage. Haematoma, if it does not subside, is best treated 
by incision — so also abscess ; usually in both cases incision on one side will 
empty the sac on both sides, since the cartilage is perforated. Dislocation 
is best treated by the use of plugs. Lateral deviation of the nose visible 
externally ('crooked nose ; ) sometimes requires the use of special appliances 
to be worn to correct the deformity. For an account of some cases see 
paper in ' Medical Chronicle,' vol. iv., 1886. 

Nasal Polypi are somewhat rarely met with in childhood ; they spring 
from the region of the middle or inferior turbinated bones as soft, grey, 
semitransparent, rounded masses ; occasionally they take origin higher up 
in the nasal cavity. Repeated removals with the use of astringents in the 
intervals is the treatment required. 1 The polypi should be taken away with 
forceps ; in some cases the tendency to re-growth is so obstinate that it is 
necessary to take away the whole of the turbinated bone from which the 
growths arise. 

Where there is nasal obstruction from chronic catarrh or cicatricial con- 
traction, the use of nasal bougies or plugs smeared with any medicament 
desired, such as iodide of lead or iodoform ointment, is useful. 

Superficial Ulceration of the mucous membrane of the nose often occurs 
in cases of chronic catarrh from any cause, and occasionally the ulcers are 
deeper and lead to perforation of the septum ; this is especially likely to occur 
from pressure of foreign bodies. We have seen perforation of the septum 
occur in a child simply from picking the nose. Perforation of the septum 
from tuberculous ulceration is fairly common and very intractable. The 
ulceration may or may not be associated with lupus of the adjacent 
skin. 

Chronic Dry Catarrh of the nose, accompanied by atrophy of the turbi- 
nated bones and their coverings, may be met with ; it is often associated with 
ozaena. The treatment is similar to that of ordinary chronic catarrh, but, 
according to Sir M. Mackenzie, the use of medicated plugs of wool relieves 
some cases. The disease is a very intractable one : painting with glycerine 
is occasionally useful. 

Congenital Malformations of the nose are rare ; closure of the anterior 
or posterior nares, adhesions between the walls of the nasal fossae, perfora- 

1 Acid, tannic, parts ii ; cupri sulpha:., part i ; pulv. plumbi nitrat., part h, will be 
found a good snuff for these cases if obstinate ; the milder applications mentioned under 
Chronic Catarrh are, however, often sufficient. The occasional application of nitrate 
of silver fused on a wire is sometimes required. 



Nasal Polypi. Epistaxis y^j 

tion of the septum, and cases of cleft or flattened nose, or even of entire 
deficiency of the organ, have been met with. 1 

Malignant Polypi of the nose and nasopharynx are occasionally seen in 
children ; early removal is the only treatment, but speedy recurrence is to be 
looked for. 

Epistaxis occurs very frequently in children, sometimes as a result 
merely of cerebral congestion, the communication between the longitudinal 
sinus and the nasal veins remaining open in early childhood ; in other cases 
congestion from catarrh, or ulceration, injury, or foreign bodies, &c, may 
give rise to bleeding. Hemophilic patients frequently bleed from the nose, 
and epistaxis is a complication often met with in some of the exanthems, &c. 

Usually the bleeding ceases spontaneously in a short time ; if this is not 
so, bathing with cold water, or a little ice applied inside or over the nose, 
will usually stop the flow. Astringent powders or lotions, tannin, alum, &c, 
may be blown into the nostrils. Sometimes pressure from outside is effectual ; 
in other cases making the child stand upright, with the arms above the head 
so as to expand the chest and relieve venous engorgement, will prove suc- 
cessful. 

Occasionally the nose may require plugging. 

Nasal Deformity. — Where there is destruction of the whole or part of 
the nose, plastic operations may be employed. These must be planned 
according to the individual requirements of the case. We are rather of 
opinion that a good artificial nose is preferable to most of those obtained by 
plastic operations. Where, however, there is loss of only a small part of the 
nose, or where there is flattening without loss of substance, attempts should 
be made to improve the appearance of the child by filling up the gap or ele- 
vating the depressed part. It will be found that there is great difficulty in 
obtaining a good prominent nose by any method, and too much should not 
be promised. For details of the methods of operating we must refer to 
systematic works on Operative Surgery. 

1 For figs, of deformities vide Forster's Missbildungen des Menschen. 



75 ( ^ Diseases of the Ear 



CHAPTER XXXV 

DISEASES OF THE EAR 

Diseases of the External Ear. — The auricle may be congenitally 
absent or crumpled and distorted : for the former condition an artificial ear 
may be fitted, for the latter usually nothing can be done. 

In cases of deficient development of the pinna the ramus of the jaw may 
also be stunted — i.e. the first post-oral arch and its appendages may be ill 
developed. 1 

For an account of supernumerary auricles and fistulae, vide p. 178. 

Sometimes the ear is unduly large, and stands out prominently from the 
side of the head ; the appearance may be improved by the use of an ear 
truss, or in extreme cases by removal of a triangular portion of the ear and 
careful closure of the gap by sutures, or excision of a portion of the skin and 
cartilage from the posterior surface of the pinna, or by suturing the ear to 
the skin covering the mastoid process. 

The pinna is often the seat of eczema and chilblains, which require the 
treatment of the same affections elsewhere ; eczema most commonly attacks 
the crease between the auricle and the side of the head, and chilblains the 
free edge of the ear. 

Simple, lupous, or other tuberculous ulceration may also attack the ear, 
and we have seen the whole auricle rapidly slough away during an attack 
of whooping-cough. 

The orifice of the external meatus is sometimes congenitally closed : in 
such cases, if the tuning-fork shows the labyrinth to be healthy, a careful 
dissection may be made at the site of the orifice, or the meatus may be 
reached by incision behind the auricle and the orifice afterwards opened 
upon a bent probe. Nothing should be attempted until the child is old 
enough to have the hearing power tested, unless there is evidence of retained 
secretion giving rise to abscess, Avhen an opening must be at once made. 

The common affections of the external meatus, which in children is pro- 
portionately shallower and broader in a horizontal direction than in adults, 
are eczema, boils, accumulations of wax or epidermis, and the presence of 
foreign bodies : the first are not peculiar to children ; the last is, of course, 
commoner in them. If the foreign body has passed beyond the orifice of 
the meatus, it should be removed by gently syringing, or by means of a loop 
of silver wire, or by a probe coated with cobbler's-wax or glue. No violence 

1 As in a case of Canton's, Path. Soc. Trans, vol. xv. We have had similar cases 
under our own care. 



Inflammation of Middle Ear 759 

should be used, and it is better to leave a foreign body where it is than to 
push it further in or lacerate the meatus or membrana tympani in attempts 
at its removal. Insects, &c, in the meatus are readily killed by a drop or 
two of oil. 

Eczema, tuberculous sores, &c, may give rise to purulent discharge from 
the ear, but usually such discharge comes from the middle ear. In ail cases 
the pus should be carefully soaked up with absorbent wool and the ear 
examined ; sometimes, however, the meatus is so swollen and the child so 
intractable that no examination can be made : under such conditions the 
case should be treated as one of otitis media until, either with or without 
anaesthesia, the ear can be examined. 

The imperfect development of the tympanic bone and consequent shal- 
lowness of the meatus in children must be borne in mind ; in young infants 
the membrane lies in a more horizontal plane than in adults. 

Inflammation of the Middle Ear maybe either acute or chronic. The 
causes of acute otitis are catarrh of the nasopharynx, usually associated with 
enlarged tonsils or post-nasal adenoid growths, cold, and the exanthems, 
especially scarlet fever ; injuries also, by picking or roughly drying out the 
ear with corners of towels and so on, may rupture the membrane and set up 
otitis media. 

Case. — Chronic Tonsillitis. Post-nasal Adenoid Growths. Deafness. — Annie C, age 
9 years; admitted July i, 1884. Always healthy till scarlet fever four years ago, when 
she had sore throat, running from nose, and deafness ; worse lately. On admission, ton- 
sillar aspect ; health otherwise fair ; both tonsils bulge forwards and inwards ; nasal 
mucous membrane thickened ; upper part of pharynx stuffed full of warty adenoid growths ; 
posterior nares nearly blocked. July 24, pharynx cleared with finger, curette, and Volk- 
mann's spoon ; left tonsil removed, bled freely ; much clearer afterwards. Result, great 
improvement. February 1885, quite well. 

Sir W. Dalby 1 has pointed out that boxing the ears of children may 
give rise to nervous deafness without a rupture of the membrana tympani, 
such deafness being usually permanent and severe ; or the membrane may be 
ruptured : in such case the rupture may heal or be followed by inflammation 
of the middle ear ; or, lastly, acute otitis may be set up without rupture of 
the membrane. 

In otitis the result of throat affections the disease may be caused either 
by Eustachian obstruction, and consequent retention of secretion, or by actual 
extension of the inflammation along the tube. The symptoms are pain in 
the ear and head, deafness, and some constitutional disturbance. In infants, 
who cannot indicate the seat of their trouble, otitis should be suspected if 
there are fretfulness and restlessness, with tossing about of the head without 
other assignable cause. If these cases are left to themselves, the membrane 
soon yields, and a purulent discharge escapes from the meatus, giving 
usually great relief ; until discharge appears the condition is often overlooked 
in scarlet fever, where the attention is apt to be directed to other symptoms. 
If the membrane is examined in such cases, there will be seen all the signs 
of inflammation, redness and loss of lustre, and if pus is present it may 
perhaps be visible as a yellow discoloration of the lower part of the mem- 
brane. 

1 Brit. Med. Jour. December 23, 1882. 



760 Diseases of the Ear 

Treatment. — The throat must be attended to, and antiseptic, sedative, or 
astringent applications used, according to circumstances; next, the Eustachian 
tube must be kept open by Politzer's method : the inflation can be performed 
at the moment of the child's crying. Hot fomentations, with perhaps a leech 
behind and in front of the ear, and instillation of a drop of glycerine and 
laudanum, or glycerine and carbolic acid, into the meatus, should be employed. 
Failing relief by these means, the membrane should be carefully incised, 
either horizontally or vertically, behind the handle of the malleus, and the 
discharge allowed to escape — gentle washing out of the ear with warm 
boric lotion, and inflation of the middle ear, being also used. As soon as 
the acute symptoms have passed off, powdered boric acid and iodoform 
should be blown into the ear after drying it carefully with absorbent wool 
two or three times daily, according to the amount of discharge. 

The dangers of otitis media are manifold : first, deafness ; and secondly, 
extension of inflammation, which may reach the mastoid antrum or the 
mastoid cells, perforate the roof of the tympanum, or the sutura petro- 
mastoidea, which is still open in infancy, and so directly reach the brain. 
Cerebral abscess and meningitis are not remote dangers. Or the carotid 
artery may be opened by ulceration and fatal bleeding ensue ; or throm- 
bosis of the lateral sinus and pyaemia may result. Extension of mischief 
to the temporo-maxillary joint may occur, with stiffness of the articulation. 
The amount of deafness depends rather upon the injury done to the laby- 
rinth, upon interference with the mobility of the ossicles, or upon fixation of 
the stapes, than upon destruction of the membrana tympani. 

The dangers to life are to be met by providing free drainage for discharge 
and keeping the cavity aseptic as far as possible. If there is any pain, 
swelling, or tenderness over the mastoid process, an incision should be at 
once made down upon it ; if no pus is reached and the symptoms are urgent, 
the bone must be carefully gouged away just behind and level with the roof 
of the meatus until the cavity of the antrum is reached. It must be remem- 
bered that in children the mastoid cells are not well developed and vary 
much in size, and that the lateral sinus descends less than half an inch 
behind the meatus. Swelling and tenderness over the mastoid process 
does not always mean inflammation of the mastoid antrum or cells, but may 
be the result of extension superficially of inflammation of the meatus or of 
irritation of the mastoid lymphatic gland. Even if pus is not reached 
at the time, relief may be given and an easier way for discharge made ; but 
the removal "of bone should be free if the symptoms are definite, and, 
if possible, an opening should be made through which lotion can be 
syringed into the external meatus. In neglected cases extensive necrosis 
may occur, and the walls of the meatus, or even the greater part of the petrous 
bone, may come away as sequestra. It is common to find the lymphatic 
glands just below the ear inflamed, and they may cause much pain, or may 
suppurate and discharge through the walls of the meatus. In the early stages 
of glandular inflammation, hot belladonna fomentations will often arrest the 
mischief; if suppuration occurs, the abscess should be early incised. 
Suppurative meningitis, if diffuse, is not amenable to treatment, but localised 
cerebral abscess, which may be either in the temporo-sphenoidal lobe or 



Otitis Media 761 

cerebellum, should be treated by trephining" the skull and opening the 
abscess. 

Facial paralysis, which not uncommonly results from otitis media, is 
peripheral, and the result of pressure upon the nerve in the wall of the 
tympanum ; the paralysis usually disappears on subsidence, of the otitis, but 
may be permanent. Chronic otitis media may be due to the same causes 
as the above, but is often tuberculous ; it may last for years, and give rise to 
occasional attacks of acute earache. Chronic otitis is always a source of 
danger, and should never be neglected ; the tympanic cavity should be care- 
fully cleansed by gentle syringing, and then the mucous membrane got into 
a healthy state by insufflation daily of the iodoform and boric powder, or 
by the use of slight astringents, such as alum, gr. iij to §j, or sulphate of zinc r 
gr. j-ij to 5J ; boric and carbolic lotions are perhaps the most generally 
useful. On examination of the ear in these cases the membrane is usually 
almost entirely gone, and the.ossiclesmoreor less completely destroyed ; the 
hearing power is impaired, but seldom entirely lost. The complications met 
with in the acute variety are also liable to occur at any time in the course of 
a chronic case. Small perforations of the membrane in children readily 
heal, but it is exceptional to meet with them. 

In very chronic otorrhcea masses of granulation tissue, springing from the 
tympanic cavity, less often from the membrane or walls of the meatus, may 
appear, and form the commonest kind of aural polypus ; fibrous, mucous, and 
adenomatous polypi are much rarer. Polypi are to be treated by removal 
with forceps, or scraping away, and the application of some caustic, of which 
we prefer solid nitrate of silver fused on a loop of wire ; crystals of per- 
chloride of iron or chromic acid may be used if preferred, and the ear should 
be washed out with a solution of rectified spirit as strong as can be bornef 
without pain (usually 1 in 4 to 1-2 can be employed). Boric and tannic 
acid and iodoform insufflations should be used between times. It is often 
necessary to remove these polypi several times before they cease growing. 
All abscesses burrowing about the ear must be opened and well drained, and 
the general health, as well as the condition of the throat and nose, carefully 
looked after. Eustachian catheters require an anaesthetic in children, and 
should only be used when Politzer's method fails. 

The general routine method, then, of treating otorrhcea (' otitis media 
suppurativa') may be given thus. (1) Dry out the ear with absorbent 
wool. 1 (2) Examine with a speculum, and through this puff a powder of 
equal parts of iodoform and boric acid, once, twice, or three times daily, 
according to the amount of discharge. 2 (3) Inflate the ear by Politzer's 
method once daily. (4) Watch for, and open early, any mastoid or glan- 
dular abscess. (5) Protect from cold, and take care of the general health. 3 
(6) Never neglect the least earache. (7) See that the throat and naso-pharynx 
are healthy. 

1 Where hospital patients cannot be seen daily the friends shotild syringe out the ear 
with warm boric lotion. 

2 We prefer a simple speculum and the use of an aural reflecting mirror, but Brin ton's 
: otoscope ' may be used. 

5 A clean plug of absorbent wool should be put into the meatus and changed two or 
three times daily or more, according to the amount of discharge. 



762 Diseases of the Ear 

It must be remembered that pain in the ear may be a result of carious 
teeth, cervical adenitis, or any source of pressure upon the nerves supplying 
the auricle or meatus, as well as of ear disease. 1 

Affections of the Labyrinth in children may be either congenital, or the 
result of injury, or of extension from otitis media, or of congenital syphilis. 
The latter form usually comes on about the seventh to twelfth year, increases 
rapidly, affects one ear first, and leads to severe or total deafness ; it is 
rarely remediable, though mercury and iodide of potassium should be tried. 
If the case comes under treatment in an early stage, there is some hope of 
recovery. Deafness in children should be seen to at once, and care should 
be taken, in those in whom restoration of hearing cannot be complete, to 
make them read and speak aloud to prevent the tendency to become mutes. 
Deaf-mutes should be taught the 'oral method.' 

Intracranial Abscess. — Should there be evidence of intracranial abscess, 
as shown by fever, vomiting, otorrhcea, pain in the side of the head, convul- 
sions, squint, hemiplegia, more or less loss of consciousness, and perhaps optic 
neuritis, the ear should be examined and well cleaned out, so as to avoid 
any further retention of pus in the tympanum ; a flap of soft parts should then 
be turned up by a curved incision, exposing the temporal bone above and 
behind the ear ; a circle of bone should then be gouged away, having its 
centre opposite the posterior superior quadrant of the meatus, and from ^ in. 
to f in. from the meatus, according to the age of the patient.' 2 Having removed 
the bone, if no sign of abscess appears, the dura mater should be incised and 
the brain punctured first directly inwards, then forwards and inwards, and 
finally backwards, so as to tap any abscess situated either in the cerebrum 
or cerebellum ; if pus is found, the opening should be enlarged, and the 
abscess drained and treated on general principles. The mastoid antrum 
and cells, if not previously cleaned out, should be dealt with at the same time. 
{Vide also p. 498.) Barker points out that a single rigor, followed by sub- 
normal temperature, slow pulse, and 'sluggish, but perfect, cerebration,' may 
be met with in cerebral abscess. There appears to be no certain means of 
distinguishing temporo-sphenoidal from cerebellar abscess, but in the latter 
the pain is usually occipital, and there is retraction of the head ; the amount 
of paralysis in either case is inconstant. Temporo-sphenoidal abscess is 
about three times as common as cerebellar, according to Barker. He also 
believes that abscess in the brain is much rarer than meningeal or subdural 
suppuration. 

Not very long ago we had under the care of our colleague Dr. Hutton and 
ourselves, a boy eleven years old, suffering from double otitis after small- 
pox. On admission there was discharge from both ears, with pain in the 
left, and in the left temple. Shortly after entering the hospital he had 
a succession of rigors. The ears were full of thick discharge, and each 
contained a small polypus. The ears were cleaned out, the polypoid granu- 

1 Vide Hilton's Rest and Pain. 

2 Barker gives h in. above and \ in. behind the centre of the bony meatus for sub- 
dural abscess over the roof of the tympanum, and h in. directly behind the meatus for sub- 
dural abscess in the groove of the lateral sinus. By enlarging the opening upwards and 
backwards, and then puncturing the dura mater, avoiding the lateral sinus, any abscess 
in the brain would probably be reached. 



Intracranial Abscess 763 

lations removed, and the acute symptoms disappeared. There was no 
mastoid trouble. A week later the boy became drowsy, with a subnormal 
temperature ; there was no paralysis, no spasm, except possibly of the 
muscles of the left side of the face, but this was probably rather paresis of 
the right side. Slight cloudiness of the left optic disc was found ; there was 
no apparent tenderness. The next day a circle of bone was removed from 
above and behind the meatus, the dura mater opened, and the brain explored 
systematically, but no abscess was found in the temporo-sphenoidal region. 
A second flap of skin was then turned upwards from the occiput, and a 
small aperture made in the skull ; a trocar was then passed into the cere- 
bellum, and offensive pus escaped ; the cannula was left in, but the boy died, 
apparently of shock, six hours later. From examination of the head we should 
advise in such cases the removal of a circle of bone immediately above the 
external auditory meatus, at a distance from it varying" from i in. to 1 in., 
according to age ; the dura mater should then be stripped back until the 
roof of the tympanum is exposed, and any pus lying there evacuated. 
Next, the dura mater should be incised and the brain explored, first directly 
inwards, in the posterior part of the temporo-sphenoidal lobe, and, failing 
this, backwards, inwards, and downwards, and finally forwards. Either a 
temporo-sphenoidal or cerebellar abscess would probably be thus reached. 
If, however, the symptoms are fairly definite and no abscess is found in this 
way, the skull should be opened midway between the superior and inferior 
curved lines of the occipital bone, and the cerebellum explored. It is 
readily reached in this position. 

It should be remembered that a cerebral abscess maybe latent — i.e. may 
exist and give rise to few or almost no symptoms — and yet may cause sudden 
death, probably often by rupturing into the lateral ventricle. 

In the above case there were no definite symptoms to point to cerebellar 
rather than to temporo-sphenoidal abscess, and it was only, failing the 
latter, that, feeling strongly that an abscess existed somewhere, we sought 
it in the cerebellum. {Vide also Cerebral Abscess.) 

In cases of tuberculous otitis we have been in the habit of freely scraping 
out the middle ear with a Volkmann's spoon, removing all cheesy bone and 
granulation tissue with or without a mastoid incision, according to the extent 
of the disease. The scraping should be thorough, and should be repeated if 
necessary. 

Where symptoms of septic absorption and thrombosis of the lateral sinus 
and internal jugular vein exist, the vein should be exposed and ligatured, 
and then together with the sinus laid open and cleaned out. Similar con- 
stitutional symptoms with orbital swelling and proptosis would indicate 
thrombosis of the cavernous sinus, which occasionally occurs, and might 
possibly be reached by operation through the orbit, though we are not aware 
that this has been hitherto attempted. 

Note. — In examining the tympanic cavity post mortem, it should be remembered that 
the presence of a puriform fluid in the middle ear of infants is common, and apparently 
rather the result of the changes that take place after the entry of air into the tympanic 
cavity than a pathological condition. 



764 



Tumour Grozvth in Childhood 



CHAPTER XXXVI 

TUMOUR GROWTH IN CHILDHOOD 



Tumour Growth in Childhood. — As might be expected in a rapidly 
growing organism, the connective-tissue group of tumours is that almost 

exclusively met with in children. 
Sarcoma, myxoma, enchondroma, and 
osteoma are the common forms of 
new growth, and these are usually in 
an embryonic and therefore unstable 
and rapidly growing form. Soft (en- 
cephaloid) carcinoma is occasionally 
met with, it is said, especially in the 
eye, kidney, and testicle ; but it is 
probably that most of the so-called 
carcinomata are really sarcomata. 1 

Sarcomata are not rare in chil- 
dren ; they are commonly of the small 
round-celled or mixed varieties, are 
most often seen as periosteal growths, 
and often follow injuries. They are 
met with in connection with the jaws, 
the skull, and the long bones, most 
commonly grow rapidly, early become 
generalised, and are speedily fatal ; 
we have met with rapidly' growing 
sarcoma as a sequel of acute peri- 
ostitis. 

The eye 2 and the skin are not 

rarely the seat of sarcoma ; we have 

seen a melanotic spindle-celled growth > 

in the skin of the dorsum of the foot. The kidney is occasionally the 

subject of congenital sarcoma {vide Chapter on Diseases of the 

Kidney). 

1 These are also common sites for sarcomata in childhood. 

2 As in the following case, figured above (fig. 191) : 

Sarcoma of Eye and Jaw, &c. — Walter W. , aged 1 year 7 months ; admitted July 23, 
1884. At birth, in the left eye it was noticed that the pupil was white ; three months ago 
the eye began to swell ; three weeks ago the right half of the lower jaw began to enlarge 




Fig. 191. — Sarcoma of the Lower Jaw and 
Eyeball in a child aged 19 months. 



Neuroma of Posterior Tibial Nerve 



765 



Where sarcomata occur in the limbs, early amputation is the only treat- 
ment ; in the case of renal growths the balance of evidence is against any 
operation. Testicular tumours should be removed as soon as they are 
recognised, and growths in other situations must be treated as the individual 
case may require. 

We have met with a Neuroma only once in a child, and the case is of 
sufficient interest to be worth recording in detail. 

Neuroma of Posterior Tibial Nerve. — Alice M., age 11 years ; admitted May 9, 1885. 
Healthy girl. Three years ago first complained of pain in the right ankle and walked 
with a limp. Has been getting worse 
lately, and the ankle has become more 
tender. On admission there is much 
tenderness along the inner side of the 
ankle, extending for about 4^ inches 
up the leg. There is swelling and 
some heat over the painful area, which 
seemed to correspond to the tendons 
of the tibialis posticus and flexor longus 
digitorum. The case was thought to 
be one of tenosynovitis, and the child 
was sent out in a plaster-of- Paris splint 
on May 20. Re-admitted November 5. 
Condition unaltered ; much pain and 
tenderness. November 23, the limb 
was rendered bloodless and an incision 
made over the swelling in its whole 
extent, when a firm, pale, lobulated 
tumour was found connected with the 
posterior tibial nerve ; the growth was 
encapsuled and turned out fairly freely ; 
it reached from the middle of the leg 
to nearly the middle of the inner side 
of the foot, and was about the size of 
two average fingers. The nerve was 
inextricably involved and ran through 
it. The whole tumour and the nerve 
were removed, about 5 inches of the 
latter being taken away. No large 
vessel was injured, but there was 
troublesome bleeding from some small 
ones. She did not bear the operation 
well. For some days she had hyper- 
aesthesia of the opposite limb. The 

wound healed well, but somewhat slowly. On December 2 it was noticed that ankle- 
clonus was well marked. On the 13th the whole sole of the foot nearly to the root of the 
toes was completely anaesthetic, as well as almost the whole of the plantar surface of the 




Fig. 192. 



-Enchondroma of Cervical Spine and 
Fingers. 



painlessly and to grow rapidly in size. No cause known. On admission, well nourished. 
The left eyeball was enlarged and protruded ; it was irregular in shape and reddened ; 
the cornea was vascular. The lower part of the right side of face much enlarged ; large 
veins on the surface, which was nodulated ; swelling involved whole thickness of hori- 
zontal ramus of jaw, projecting outwards and into mouth, which could not be closed. 
Teeth displaced and loose ; no ulceration ; no disease elsewhere. August 1 , swelling 
increasing rapidly, not much pain, losing flesh. Discharged August 12, and died at home 
a few weeks later. 



766 



Tumour Growth in Childhood 



little toe. The sides of the foot, the ball of the great toe, and to a less extent the balls of 
the second, third, and fourth toes, together with the whole of their plantar surface, were 
partially anaesthetic. Sensation elsewhere normal The calf muscles somewhat wi 
In January 1886 she was practically as on discharge, but could walk a little and move the 
foot freely without pain. Nutrition of foot good. Microscopically the tumour was a 
myxo-fibroma. Nerves could be traced for some distance in it and then became 
degenerated and lost. March 23, 1888, quite well ; no return of sensation ; foot warm ; 
arch good ; walks well ; no pain or tenderness. 

Of the more innocent growths the Enchondromata are the most common ; 
they are usually multiple, occur on the fingers, and may be congenital ; they 
tend to grow with more or less rapidity, and if they cause inconvenience may 
require amputation of one or more fingers. Removal of the growth alone 
is rarely satisfactory, since it has been shown that the tumour is very often 
central in origin, as in the following instance : 




Fig. 



-Multiple Enchondromata of the Forefinger. 



Multiple Enchondromata of the Fingers. — Samuel M., age 7 years 9 months ; admitted 
January 28, 1885. When five months old swellings were noticed on the fore and middle 
fingers of the left hand ; these have gradually increased, and give rise to much pain if 
injured ; at other times they are painless. On admission, is a thin, unhealthy boy. Several 
cartilaginous masses are growing from all the fingers of both hands ; the swellings vary 
in size from a pea to a small nut, the largest is in the flexor aspect of the left middle 
finger ; this finger cannot be flexed. The fingers are large and distorted, with some 
lateral deflection of the second and third fingers of the right hand. The worst, the left 
middle finger, was amputated at the metacarpophalangeal joint, and the theca was 
stitched up with catgut (Treves). A section of the finger showed a cartilaginous tumour, 
the size of a small walnut, growing from the proximal end and from the central part of the 
epiphysial line of the second phalanx. The flexor tendon was stretched over the tumour. 
A smaller mass sprang from the distal end of the same phalanx. The wound soon healed. 
The other fingers were not touched, as they gave rise to no great inconvenience. The 
cervical vertebrae were similarly affected (vide fig. 192), and the feet are now (1899) also 
the seat of cartilaginous outgrowths. 



Osteomata 



7^7. 



Another case is shown in fig. 193. Osteomata are usually sessile, com- 
posed of cancellous tissue capped with soft cartilaginous or myxochondro- 
matous tissue ; they most frequently spring from the neighbourhood of an 
epiphysial line, may be multiple, and are occasionally hereditary. These 
growths may require removal on account of their interference with the 
movements of a joint or of pain ; if chiselled or sawn through at the base, 
they do not recur. We have most often seen them at the upper end of the 
humerus, as in the case quoted. 

Exostosis. — Sarah E. T. , age 10 years 6 months ; admitted January 9, 1884. Tumour 
first noticed six weeks ago ; has grown slightly since ; no cause known. On admission 
an exostosis as large as a good-sized walnut was found on the posterior aspect of the 
humerus, 2 inches below the acro- 
mion ; the swelling was bilobed. 
Removed by chisel antiseptically on 
January 17 ; the surface was cartila- 
ginous, the deeper part composed, of 
cancellous tissue. Wound healed on 
January 22. 





[95. — Congenital Serous Cyst of the Back. 



Fig. 194. — Hygroma of the Neck, asso- 
ciated with Macrogiossia. Mr. White- 
head's case. The tongue is protruding. 
Vide also Najvus. 

Besides the growths already 
mentioned, there is the large 
group of Congenital Fibrous 
and Cystic Tumours : the 
former may occur in any part, 
the latter are said to be limi- 
ted to the trunk and head ; 
we have, however, removed a 

multilocular cystic growth from the back of the thigh in a child. 1 Cystic 
hygroma of the axilla is not Aery uncommon ; it usually extends up into 
the neck. The cystic tumours may be divided into several classes. A 
large proportion are really cavernous lymphangiomata (lymph nasvi) ; such 
are hygroma, hydrocele of the neck (a unilocular hygroma), the tumour 
mentioned above as removed from the thigh, and many others. In the 
second group are those cystic tumours resulting from degeneration of a blood 
naevus ; in these the fluid may be clear, or more or less stained by admixture 
of blood pigment. The third group includes cystic formations by degenera- 
1 Morgan has recorded a hygroma of the thigh in the Clin. Soc. Trans. 1884. 



768 



Tumour GrozvtlL in Childhood 



tion in fibrous or teratOmatous growths ; and the last includes dermoid cysts, 

the result of involuted or 'dissociated' blastoderm. 1 

These ' dermoid' cysts may be met with in the course of any of the lines 
of union of the embryo, e.g. along the median ventral and dorsal lines of the 
trunk, in the face, head, palate, neck, &c. These cysts are due to closing 
in of the tissues over a portion of epiblast ; hence the cyst wall is com- 
posed of more or less perfectly formed skin, with hairs, sebaceous glands, 

&c. ; lying in the cavity of the cyst 
will be found sebaceous matter 
and hairs, and epidermic scales. 
Perhaps the commonest sites for 
these tumours are the outer angle 
of the orbit (orbital fissure), the 
inner angle (lachrymal fissure), and 
the median ventral line. In the 
auricle they may result from inclu- 
sion of skin between the tubercles 
by fusion of which the auricle is 
formed. They are sometimes met 
with in the middle line of the nose, 
and cause much disfigurement by 
the growth of hair from their in- 
terior ; in this position they must 
be due, as pointed out by Bland 
Sutton, to some irregular laying 
down of the skin, since there is no 
line of fusion in the development 
of the embryo at this spot. Pro- 
bably the growth of the nasal 
bones and lateral cartilages causes 
some inversion of the skin. The growth of hair seen upon the nose in later 
life suggests a possible similarity between the two conditions. 

Dermoid cysts differ from acquired sebaceous cysts in that they are con- 
genital, that they lie deeper than the ordinary wen, being in the subcutaneous 
or even in the submuscular tissues, and in the case of the skull they may 
cause partial or complete absorption of the underlying bone. The- skin over 
a dermoid cyst is usually of natural appearance and of normal thickness, not 
thinned and showing dilated capillaries, as is often the case in sebaceous 
cysts. In sebaceous cysts the aperture of the gland is often visible as a black 
speck : no such mark is seen in a dermoid tumour. Should the dermoid 
cysts grow and become unsightly, they should be excised, but it must be re- 
membered that their removal may be dangerous on account of their deep 
relations, and that, as they are lined with more or less perfect skin, complete 
removal is required, and it is not sufficient to lay open and scrape the cyst 
wall. 

1 The relations of congenital ' displacements ' to subsequent tumour growth cannot, of 
course, be discussed here ; probably only a small number of cases are to be thus accounted 
for {vide Cohnheim ; also Eve's Lectures at the Roy. Coll. of Surgeons, 1883, and Bland 
.Sutton's Lectures on Evolution in Pathology, Brit. Med. Jour. 1889). 




Dermoid Cyst of Orbit. 






Dermoid Tumours 



769 



Mr. Bland Sutton, in his lectures delivered at the Royal College of Surgeons, classifies 
dermoid tumours as (1) Sequestration dermoids; (2) Tubular dermoids; (3) Ovarian 
dermoids. 

The first occur usually in the lines of union of the embryo, or are a result of accident ; 
a sort of subcutaneous grafting of dermal tissue. 

Tubulo-dermoids arise in connection with ' obsolete canals ' ' associated with the primi- 
tive alimentary canal.' They may exist as 'dermoid cysts,' 'dermoid tumours,' or as 
'thyroid dermoids,' or 'congenital adenomata.' The first two varieties do not differ 
from sequestration dermoids, except that they are more complex. Mr. Sutton calls them 
thyroid dermoids because of their histological resemblance to the thyroid body. ' They 
present easily recognisable characters: (1) they arise in obsolete sections of the gut; 




Fig. 197. — ' Dermoid ' Cyst of the Forehead. Mr. Hardie's case. 



(2) resemble structurally the thyroid body ; (3) are frequently associated with striped or 
unstriped muscle fibre; and (4) are usually congenital.' 'The most typical specimens 
occur in the neighbourhood of the coccyx, in the tongue, and in the neck.' 1 

After further details, for which we must refer to the ' British Medical Journal,' March 2, 
1889, whence the above extracts are taken, Mr. Sutton concludes his most interesting 
account of these curious growths by remarking : ' It is an interesting fact that the six 
obsolete canals existing in the embryo of a mammal, namely, the infundibulum, neuren- 
teric passage, post-anal gut, cranio-pharyngeal canal, thyreo-lingual duct, and the duct of 
the yolk sac, should all have direct relation with the alimentary canal, and each be directly 
associated with dermoids, often of considerable complexity, and with a peculiar form of 
tumour, identical in structure with the thyroid body.' Some time ago we met with a 
case of an infant, a twin three days old, who was the subject of a large unilocular cystic 



1 Vide also Marshall, Jour. Anat. and Phys. vol. xxv; 



3D 



770 



Tumour Groivth in Cliildhood 



tumour growing from beneath the coccyx, and forming a somewhat pendulous l 
hanging from the perinaeum. The cyst was thin-walled, and about the size of the child's 
head. A day or two after admission the cyst burst, and gave exit to about half a pint of 
clear yellow fluid— practically serum. We removed the collapsed cyst by incision, and 
found a fine channel running up into the pelvis for about i^inch. The child did well, 
and was sent out with the wound nearly healed in March 1889. Sections of the wall of 
the cyst showed a distinctly villous lining, with a single layer of somewhat indistinct 
roundish cells. 

Vide also chapter on Malformation of the Digestive Apparatus. 

An important group of tumours in childhood is formed by the fatty 
growths often met with. There may be simple general obesity or hyper- 
trophy of fat, a condition often met with in our experience in association 
with malformations such as club-foot, spina bifida, giant foot, &C. 1 Jacobi, 2 




Fig. 198. — Dermoid Cyst in the Lachrymal Fissure. A tooth is seen 
growing at the upper part of the tumour. Prof. Young's case. 



who has collected many of the cases on record of hypertrophy of the 
extremities, attributes the condition to intra-uterine venous congestion 3 in 
early fcetal life ; if, however, this occurs before the first half of intra-uterine 
life, during which no fat is said to be formed, myxomatous tissue is developed ; 
if in the later stages, fatty tissue. 

Lipoma may occur in any part of the body ; it is, however, rarely met 
with in the head. Congenital lipomata are often not encapsuled ; they are 
sometimes associated with nasvus, as in fig. 85 (n?evus lipomatodes), or, as 

1 The cervical fatty growths met with in cretins are also noteworthy in this connection. 

2 Archives of P&diatrics, February 1884. Jacobi's list contains obviously very different 
pathological conditions. Also Bland Sutton, Brit. Med. Jour. vol. i. 1890, p. 877. 

5 Busey attributes it to lymph stagnation. 



Fatty Tumours 



771 



in one case of Jacobi's, with spina bifida. Congenital sacral tumours are 
sometimes mainly fatty, as in one or two of our own cases ; but these, and 
indeed congenital lipomata elsewhere, are by no means always pure fatty 




Fig. 199. — Congenital Myxo-Lipoma of the Breast. The tumour was removed, and the 
child did well. We have lately seen a second similar case. 



growths ; fibrous, bony, or cartilaginous material may be mixed up with the 

fat, as well as naevus, muscular tissue, 1 &c. ; these more complex tumours 

belong to the teratomatous class rather than to the ordinary lipomata. 

When occurring in the foot congenital 

lipoma forms one of the varieties of 

so-called ' giant foot,' of which fig. 200 

is a specimen ; in some of these cases 

the growth is encapsuled ; in others it 

is diffuse, and after incomplete removal 

it shows a tendency to recurrence. In 

these cases of giant limb, which are 

usually unilateral, the rate of growth 

is variable, and all the constituents of 

the limb are overgrown in some cases, 

while in others the bones are enlarged, 

the vessels, muscles, and nerves being 

normal.' 2 (See also chapter on NiEVUS 

for an account of the lymphatic form 

of 'giant foot.') 

Fatty tumours of doubtful con- 
genital origin are sometimes met with, and may be the seat of myxomatous 
change, as in the appended case. 




Fig. 200.— Giant Foot (the Fatty Variety), the 
growth affecting mainly the toes, but also to 
some extent the sole of the foot. 



1 Vide Butlin, St. Earth: s Reports, 1877. 

2 Vide Anderson, St. Thomas's Hospital Reports, 1 



1884 ; Blackader, Arch, of Pediatrics, Oct. 
elephantiastischeii Format, Hamburg 1885. 



1 ; Barwell, Clin. Soc. Trans. 
1884 ; Esmarch and Kulenkampff, Die 

3 D 2 



772 



Tumour Growth in Childhood 



Case. — Congenital (?) Myxo-lipoma of Thigh. — William M., age 2 years ; admitted 
November 2, 1885. Child began to walk last January, but was weak and soon tired ; 
had a severe fall at that time. Four months ago a swelling was first notieed at the back 
of the left thigh ; it has gradually increased in size, but has never been painful. Has 
been wearing splints for rickety deformity lately. No sores about the legs. On admission, 
a very rickety child. In the middle of the back of the left thigh is a soft movable swel- 
ling, not tender, not well defined, and indistinctly fluctuating (?). The swelling is about 
the size of a large walnut or larger. November 5, an incision was made over the swelling 
between the hamstrings ; it was found to project on the inner side of the great sciatic 
nerve, and was, with some dissection, shelled out from its deeper attachments to the 
superficial layer of periosteum ; it extended from the upper border of the popliteal space 
upwards to about zh inches. The whole growth was removed ; it was fairly well en- 
capsuled, soft, and gelatinous. Microscopically it proved to be a myxo-lipoma. On 
November 16 all stitches were removed and the wound was almost healed. Sent home. 




Fig. 201. — Congenital Cystic Tumour of the Groin. Mr. Hardie's case. 

Compound Congenital Tumours occur most frequently about the sacral 
and lumbar regions ; their origin is obscure, and has been accounted for on 
the view of included fcetation, gemmation, or inclusion of a portion of the 
outer layer of blastoderm, at the time of closure of the dorsal laminae. 1 The 
tumours are often cystic, and may contain masses of fat, cartilage, bone, and 
skin elements. They vary in size, and may attain great dimensions ; their 



1 Mr. Bland Sutton divided these tumours into four classes : 1. Sacral spina bifida ; 
2. Tumours originating in the post-anal gut ; 3. Cystic tumours originating in the 
neurenteric canal; 4. Parasitic foetuses. — Erasmus Wilson's Lectures, Brit. Med. Jour. 
February 12, 1887. 



Congenital Sacral Tumours 



773 



rate of growth usually corresponds with that of the child ; they may become 
ulcerated from irritation. Such tumours give rise to trouble by their weight 
and bulk, and their interference with movement. 1 

Case. — Congenital Sacral Tumour. — Elizth. Ann T. , age 4 years ; admitted February 
2, 1885. Always a delicate child ; more so since an attack of scarlet fever at two years. 
The tumour has gradually increased to twice the size it was at birth. She has had no fits ; 
vomits frequently after meals ; cannot retain her urine, but has no incontinence of faeces ; 
sleeps badly and complains of abdo- 
minal pain. On admission, a delicate 
child. Over the lower lumbar and 
upper sacral vertebrae is a soft, pulpy 
tumour, about the size of a small 
orange ; the skin is natural over it ; 
there is no tenderness on pressure, and 
the swelling is not fluctuating. There 
is loss of power in both legs ; the child 
can draw them up in bed, but da"nnot 
support herself upon them. February 
13, the tumour was explored with a 
needle, but no fluid was found ; a 
straight incision was then made over 
the swelling and the skin reflected, 
exposing a mass of fat. On dissecting 
this carefully away a small tumour the 
size of a filbert was exposed ; this 
evidently contained fluid and could be 
seen to pulsate ; it clearly was con- 
nected with the theca ; this was left 
uninjured, and the fatty mass dissected 
away from it. The wound was drained 
and sutured ; operation antiseptic. 
On making a section of the growth a 
small nodule of cartilage was found 
in its centre. February 14, dressed ; 
about half an ounce of blood-stained 
serum escaped ; child vomited once, 
otherwise well ; no convulsions or 
pain ; tube removed. 15th, was sick 
twice yesterday, and awoke several 
times in the night, screaming. 16th, sick 
again yesterday ; no more screaming ; 
lies very quiet. 18th, dressed ; aquantity 
of serum collected beneath the skin, so 
tube was put in again ; has been very 
irritable for last two days ; sick once in 
the night ; slept well ; ice to head and spine ; no squint or convulsions ; temperature 
normal. 19th, is a little better. She became steadily worse, and died on the 21st 
with evidence of meningitis. The highest temperature was 99-2°. 

Post-mortem.— On removing the brain an excess of fluid escaped ; the surface of the 
brain was congested, but otherwise natural ; there was some matting together along the 
Sylvian fissure, but no other abnormal appearance. Spinal cord, excess of fluid and much 
congestion at the seat of the tumour and for four inches above it. The cord ended in a 




-Congenital Sacral Tumour with Talipes 



1 Vide Clin. Led. by James Hardie, F.R.C.S., Lancet, May 2, 1885. Into the subject 
of teratology it is impossible to enter here, but the reader may refer, among other works, 
to Forster's Missbildungen des Menschen and Ballantyne's Antenatal Pathology. 



774 



Tumour Growth in Childhood 



fibrous expansion which spread out over the tumour. Small portions of the tumour 
extended downwards into the sacrum. The laminae were imperfect at the seat of the 
tumour; the central canal of the cord was dilated below the mid-dorsal region, and the 
left cornu of grey matter had disappeared, leaving a hollow space. This was evidently a 
combination of spina bifida, syringo-myelia, and a congenital tumour of cartilage and 
fat. The operation was undertaken with the view of possibly relieving the cord of pres- 
sure and so removing the paraplegia, but there is much risk of meningitis in these cases. 

As these growths are usually median in position or nearly so, they 
simulate spina bifida : hence they have been called f false spina bifida ' {vide 
p. 568) ; they may have attachments within the spinal canal or pelvis. 

Any congenital tumour of the vault of the skull or over the spine should 
be looked upon with suspicion, as likely to have intimate relations with the 
cranial or spinal cavities. The appearance of the skin, the mobility of the 
tumour, its reducibility, and the effects of pressure, &c, are the points to be 
looked to {vide Chap. XXVI). It is sometimes impossible to diagnose 
naevus from other soft growths ; the presence of 
cutaneous stains or of naevi elsewhere, the effects of 
straining or crying, the possibility of partly emptying 
the tumour, and its peculiar spongy feel, must be 
taken into account {vide Chap. XX). We have 
recently (1899) na d under our care a child of a few- 
months old with a large cystic abdominal tumour. On 
opening the abdomen the tumour turned out to be a 
' parasitic foetus ' in the lesser cavity of the peritoneum. 
The tumour was firmly attached to various viscera and 
the posterior abdominal wall, but was removed. The 
child died of shock. The mass contained skin, bone, 
coils of intestine, and other imperfectly developed 
viscera. 

Treatment. — Congenital lipomata, if large, rapidly 
growing, painful, or inconvenient, should be excised. 
The congenital sacral tumours, unless for some very 
good reason, should be left alone — there is much risk 
of injury to the spinal contents, as seen in the case just related. 

Cystic growths may be treated by tapping, injection, setons, incision, or 
excision ; none of these modes are free from danger, and the last is some- 
times impossible from the extent and connections of the mass. In large 
unilocular deep-seated cysts, such as 'hydrocele of the neck,' tapping, 
followed by injection with Morton's solution if the cyst refills, is the best 
plan ; if suppuration occurs, free incision and drainage must be employed. 
The multilocular cysts are often best treated by setons, small threads 
being inserted and the process repeated if necessary. In the cavernous 
lymphatic naevi, much lymph may drain away if the growth is cut into, just 
as bleeding occurs from a blood naevus, and there is much risk of septic 
infection or exhaustion : hence these growths should be removed entire, if 
at all. 1 

In the case of giant foot the fatty variety has a tendency to steadily 




Fig. 203. — Section of Con- 
genital Sacral Tumour. 
a points to the spinal 
canal ; b to the body of 
a vertebra ; c to a mass 
of ossifying cartilage in 
the tumour. 



1 For further details vide T. Smith, Clin. 
Guy's Hospital Reports, i860. 



Soc. Trans. 1880, vol. xiii. , and Birkett, 



Congenital Sacral Tumours 775 

grow, and though pressure may slightly retard it, we have not found it suc- 
ceed as a means of treatment. Ligature of the anterior and posterior tibial 
arteries in the following case gave a good result for a time, but after a year 
or two the growth continued. In such cases the choice is between leaving 
the case alone and amputation ; the latter should only be done when the 
crippling from the presence of the growth is greater than would result from 
the mutilation. 

Case. — Pes Gigas. Lipomalous Variety. — Emily C, age 9 months; admitted June 23, 
1884. Family history unimportant. At birth it was noticed that the left foot was dis- 
tinctly larger than the right ; since that time it has steadily grown ; there has been no 
pain, and the child's health has been unaffected. [Thanks to the courtesy of Mr. Withers, 
of Sale, we were able to watch this case almost from the first.] On admission, a fat, 
healthy child ; the left foot much enlarged, chiefly the dorsum and inner side ; toes not 
affected ; skin natural, dimples on raising it ; at the outer side a few hard nodules can be 
felt. Measurements : 

At root of toes 6h in. . . Right foot 4A in. circumference. 

At middle of foot 7 J in. . ,, 4! 

Across heel and foot 8 in. . ,, 5^ ,, 

Around ankle 7 in. . ,, 5^ ,", 

Middle of calf jh in. . . ,, 75 ,, 

Elastic pressure was fairly tried for a long time prior to admission without apparently 
diminishing the rate of overgrowth. The temperature of the two limbs did not apparently 
differ, and the child could kick the foot about, though it did so clumsily. On July 2 the 
posterior tibial artery was ligatured in the middle of the leg by the usual method, a 
catgut ligature being employed ; the vessel was very small, and its pulsations feeble ; a 
drainage tube was used ; operation antiseptic ; all went on well. On the nth the 
measurements were as before, except the one at the root of the toes, which was h in. 
less ; wound almost healed. July 12, the anterior tibial artery was ligatured doubly, and 
divided between the ligatures ; the veins were included in the ligatures. 21st, first 
dressing, wound all healed; no drainage was used; measurements as on nth, except 
middle of foot | in. less. 28, Martin's bandage applied again ; the warmth of the foot 
seems in no way interfered with. August 4, measurements : Root of toes, 6| in. ; middle 
of foot, jh in. ; across heel and foot, 8 in. ; around ankle, j\ in. ; middle of calf, j\ in. 
February 1885, the foot is getting smaller in all dimensions. Subsequently the growth 
remained stationary for a while and then increased. 

lymphoma (Lympbadenoma, Lymphosarcoma is sometimes met with 
in the shape of large masses of glands in the neck (fig. 204) or elsewhere, 1 
which slowly grow and give trouble from their size, unsightliness, and pressure 
effects {vide Hodgkin's Disease), as well as ultimately cause death. 

Removal of such masses of glands is usually of only temporary value ; it 
is seldom that all can be got away, and recurrence often takes place in a short 
time. Section of such a tumour shows a pinkish-grey lymphoid tissue with 
no caseous foci. 

The following was a characteristic case : 

Case. — Lymphoma of Neck.- — John T. , age 12 years 4 months ; admitted November 
io, 1882. Family history good, except that the mother had abscesses beneath the jaw whilst 
pregnant with this child ; boy himself never very hearty, but had fair health ; four years 
ago a swelling appeared beneath the lower jaw on the left side ; this grew slowly till the 
last three months — since then it has increased rapidly ; for three weeks has had pain. 

1 Cystic lymphomata are sometimes met with, and these growths have been found in 
the rectum, among other places. 



776 



Tumour Growth in Childhood 



On admission, in the left posterior triangle is a large globular tumour consisting of lobu- 
lated lymphomatous masses; the swelling extends from i inch below the jaw to & inch 
below the clavicle, which it overhangs ; it is 5^ inches in transverse diameter ; some of it 
projects beneath the trapezius, and outlying masses reach nearly to the middle line of the 
neck ; the skin is movable over it, and it is not fixed to the vertebrce ; no marked glandu- 
lar enlargement elsewhere, though a few slightly enlarged glands can be felt in the left 
groin ; some dulness over apex of left lung ; left pupil slightly smaller and less sensitive 
than right. On November 16 the gland masses were removed, weighing 8 oz. ; most of 
the glands shelled out easily, some were adherent ; the external jugular vein was tied and 
divided ; at times when traction was made upon the carotid sheath during the operation 
the pulse was much accelerated ; the carotid sheath and cervical transverse processes were 
exposed. He bore the operation well and lost little blood. Operation antiseptic, with 

sponge pressure ; recovery uninterrupted ; 
antiseptics were left off on December 6, and he 
was discharged with a small superficial wound. 
February 1883, the boy has been better since 
the operation, but new masses of glands are 
already beginning to enlarge, though at and 
after the operation none could be felt. 

Another case is shown in fig. 204. 
It is not at all uncommon to find cases 
in which certain of the glands have 
broken down and discharged, while in 
other respects the conditions resemble 
lymphoma rather than tuberculosis. 
We have accounted for these cases 
by supposing that tuberculosis and 
Hodgkin's disease have co-existed. We 
have seen lymphoma also appear in 
a child the subject of hip disease. 
Variation in the size of the swellings, 
associated with fever, but subsiding 
without suppuration, is also often seen. 

IVEultil ocular Cystic Growths of the Jaws arise from epithelial 
ingrowths from the surface of the gum, which afterwards become shut off and 
develop cysts ; they may be congenital or occur in infancy. Besides these, 
two other forms of cyst are found associated with the teeth (dentary cysts) : 
(1) Cysts originating in connection with the tooth follicles — follicular, or, it 
they contain teeth, dentigerous cysts : (2) Periosteal cysts, originating beneath 
the periosteum of the jaw. 

Dentigerous cysts arise from mal-placed or mal-developed teeth, and may 
occur at any part of the jaws ; they contain clear, serous or glairy, white or 
coloured fluid, rarely pus. Most often they are associated with the perma- 
nent, sometimes with the milk teeth. Eggshell crackling, the presence of 
fluid, and suppression of a tooth are the common indications of the nature of 
these swellings. (Eve, 'Brit. Med. Jour.,' Jan. 6, 1883; Heath, 'Lancet, 5 
1887.) 

For further details on the question of tumours we must refer to the 
general text-books. 




Fig. 204. — Lymphoma of the Neck. 



777 



CHAPTER XXXVII 

DISEASES OF THE THYROID AND THYMUS 

Acute Enlargement of the Thyroid. — A slight enlargement with 
tenderness of the thyroid gland is not uncommon, but any acute enlarge- 
ment, the result of inflammation, is very rare. A typical case of this kind is 
recorded by Dr. T. Barlow, 1 in a boy of three years. The symptoms at first 
consisted in pain in the neck on movement, feverishness and slight enlarge- 
ment of the thyroid gland. Later the swelling considerably increased ; the 
temperature varied from ioo° to 103 F. ; there was some difficulty in 
swallowing, but no marked dyspnoea. In four or five days the swelling- 
began to subside ; he finally made a good recovery. 

Chronic Enlargement. Goitre. — Simple or cystic enlargement of the 
thyroid is sometimes met with in children, most commonly in the inhabitants 
of certain hilly districts such as Derbyshire ; it is, however, met with in some 
cases among town-bred children, both with and without a family history of 
goitre. 

In the case here figured half the gland was removed ; it consisted of a 
mass about the size of a small orange ; in it were many cysts, the larger of 
which contained reddish-yellow fluid. The child did perfectly well, but died 
some months later of scarlet fever ; the other half of the gland had not 
appreciably altered after the operation. 

We have been three times called upon to perform tracheotomy in young 
people for urgent dyspnoea, the result of pressure of an enlarged thyroid 
gland ; in two cases the patients were young adults, the third was an ill- 
developed, idiotic child, in whom there was enlargement of the tonsils, with 
post-nasal vegetations ; these had been dealt with once with marked im- 
provement, but on the second occasion sudden dyspnoea, evidently due to 
pressure of the enlarged thyroid, was brought on by an attempt at examina- 
tion, and on administering chloroform the breathing stopped ; tracheotomy 
was performed, and the child did fairly well for a day or two, but died of 
bronchitis on the 3rd or 4th day. The operation under such circumstances 
maybe of extreme difficulty alike from the presence of the large mass of 
gland, from the engorgement of the vessels, and from the altered shape of 
the trachea, which is compressed laterally. A specially long tube is required 
to reach down below the constricted part of the windpipe. There is no 

1 ' On a Case of Acute Enlargement of the Thyroid Gland in a Child,' by Dr. T. 
Barlow, Clin. Soc. Trans, vol. xxi. 



778 



Diseases of the Thyroid and Thymus 




doubt that in any case where attacks of dyspnoea, ' thyroid asthma,' have 
recurred, either removal of part of the gland or division of the isthmus 
should be performed in an interval between the attacks. 1 In simple cases 
of goitre the treatment is the same as for adults. 

We have divided the thyroid isthmus in a young gentleman of sixteen, in 
whom acute attacks of almost fatal dyspnoea had more than once occurred. 

The trachea was much flattened late- 
rally ('scabbard trachea'). Three weeks 
after operation the gland had resumed 
nearly its normal size. In another case 
the operation was done during an 
attack, and the patient died a few 
hours later from rapid oedema of the 
lungs. In another, part of the gland 
was removed and tracheotomy per- 
formed ; the patient recovered, though 
in cases where tracheotomy is neces- 
sary the danger to life is much in- 
creased. 

It is not very uncommon to see 

children in whom the thyroid is 

slightly enlarged and sometimes pain- 

1 ful and tender, but in whom there is 

|p J|| 1 1 no very great deformity and no cystic 

% l development. These cases of ' simple 

Fig. 2o 5 .-c y stic Bronchocele in a Child. bronchocele ' may be met with at any 

age, but are perhaps most common 
-about puberty. Under treatment with iodine or arsenic internally, and 
weak red iodide of mercury ointment, cautiously used, externally, the gland 
usually returns to its natural size. Iron is required if there is anaemia. 

The thyroid gland is usually absent in cases of myxcedema or ' sporadic 
cretinism ; ' in any case of wasting or disease of the thyroid the possibility 
of myxcedema must be borne in mind. (See p. 559.) 

Thymus Gland. — The thymus body or gland reaches its greatest size at 
two years of age, after which it dwindles, and by puberty is in most cases 
reduced to a mere vestige. At birth it measures some 2 in. in length and 
perhaps \\ in. in breadth, and weighs about £ oz. At two years of age it 
weighs from i| to 2 oz. It is situated behind the upper piece of the sternum, 
reaching as low down as the fourth costal space ; it lies partly on the 
pericardium, the aortic arch, and large vessels. 

But little can be said concerning the diseases of the thymus. Some 
authors have attributed laryngismus and spasm of the glottis to enlarge- 
ment of the thymus and a consequent pressure on the nerves or trachea 
itself. It is very doubtful if laryngismus is due in any way to hypertrophy 
of the thymus, but cases in which there was evident pressure on the trachea 
by an enlarged thymus have been recorded by Goodhart, Jacobi, and 
Baginsky. Sudden death from spasm of the glottis is not uncommon during 
the first two or three years of life, and this has in some cases been attributed 
1 Vide Med. Chron. vol. xi. 1890. 



Thymus Gland 779 

to the presence ot an enlarged thymus (Pott). We are by no means con- 
vinced of this. It is common to find small cysts at first sight looking like 
abscesses scattered through the substance of the thymus ; these have been 
attributed to syphilis. Jacobi has noted an excessive quantity of connective 
tissue in the thymus of syphilitic children. He has also observed tubercu- 
losis of the thymus in cases of general tuberculosis. Demme has recorded 
a case in which caseous masses were found. The thymus when it becomes 
tuberculous probably does so from contact with caseous mediastinal lymph 
glands, as in case related at p. 329. In some recorded instances it appears 
that sarcoma has originated in the thymus. 



780 Diseases of the Skin 



CHAPTER XXXVIII 

DISEASES OF THE SKIN 

During intra-uterine life the foetus is surrounded by the liquor amnii, which 
softens and soddens the cutaneous surface. After birth the skin is subjected 
to the drying action of the air and the epidermis quickly assumes its normal 
condition ; it is, however, exceedingly easily fretted and excoriated by 
prolonged contact with the urine and faeces, and also by the hot water and 
soap of its bath. It is hardly surprising to find that under these new con- 
ditions the skin is often injured, especially when we remember the delicate 
nature of the horny layer of the epidermis in the infant. In consequence or 
the rapid growth which is taking place, there is necessarily a continual 
building up of the tissues of the skin to keep pace with body-growth, and any 
interference with the infant's digestion or assimilation of its food is ex- 
ceedingly likely to interfere with the nutrition of the skin. This is seen in 
various conditions of wasting during infancy ; the skin becomes rough and 
harsh, and the slightest irritation from the urine or faeces, or friction at the 
flexures of the joints, gives rise to an erythema, eczema, or to excoriations. 

Reflex inflammations are more common during infancy than in later life, 
a transference of inflammation readily taking place from one part to an- 
other, or an irritation present in one place may give rise to an inflammatory 
lesion at a distance. In this way we find blotches or scaly spots around the 
mouth and on the face of children who are suffering from dyspepsia or 
gastric catarrh, or herpetic patches in those suffering from pneumonia or 
bronchial catarrh. Urticaria or erythematous blotches may be the result of 
indigestible food in the stomach, or the pressure of a tooth upon the gum, 
or the presence of acari burrowing beneath the skin. 

Lesions of the skin are exceedingly common during infancy and child- 
hood, and we find eczema, intertrigo, urticaria, and dermatitis among the 
most frequent ailments at this period. 



Eczema 

Eczema during infancy, while proving amenable to treatment, is ex- 
ceedingly apt to relapse, and in aggravated cases it forms one of the most 
troublesome complaints with which the practitioner has to deal. Probably 
most physicians can call to mind cases of eczema in infants a few months 
old which have improved for a while, then relapsed again and again, and 



Eczema 781 

for which numerous ointments, lotions, powders, and medicines have been 
tried in vain. While the majority of these cases get well as the end of the 
first year is approached, or only relapse occasionally, in many cases the 
eczema continues to give trouble for years, or even for life. 

The causes of eczema in infants are various, though, indeed, but little is 
known for certain about many of them. In some cases, especially in the 
local eczemas, there are irritants at work, such as scabies, pediculi, and the 
fretting produced by napkins constantly wet with urine or faeces. There 
cannot be a doubt that there is a close relation between the condition of the 
skin and the alimentary canal. It is interesting to note that if a healthy 
infant gets an attack of dyspepsia or diarrhoea, its muscles become flabby, 
there is some wasting, and the nutrition of the skin is lowered ; and now 
the contact of urine or soiled napkins sets up an irritative erythema or 
eczema, the irritation of the soiled napkins being powerless to excite an 
excoriation until the nutrition of the skin is interfered with by faulty 
assimilation. One of the commoner internal causes of eczema in infants and 
young children is an abnormal condition of the alimentary canal ; probably, 
in some instances, the eczema is due to a mal-assimilation or insufficiency 
of food, and in consequence the nutrition of the skin suffers. Eczemas are 
usually worse during the cold east winds of spring. 

In what class of children is eczema the most common ? The answer 
must be that eczema may be found in children of every type and of every 
social grade. In the first place, it must be said that eczema is by no means 
uncommon in infants and children who are apparently in perfect health ; and 
breast-fed infants suffer as well as artificially-fed infants. We have fre- 
quently noted in hospital that children admitted for some other disease, and 
who are quite free from any skin trouble, develop eczema as they become 
fat and well. In these cases there is a strong presumption that over-feeding 
may have something to do with the eczema ; it is certainly true that very 
fat children are often eczematous, and it is very possible that strong, 
healthy children with large appetites may habitually be overfed, and the 
system seek relief, as it were, in an acute or chronic discharge from the 
skin. Perhaps in some of these cases there is a history of eczema in the 
parents. 

On the other hand, as already remarked, dyspeptic children, and those 
who are badly or poorly fed, also suffer from eczema. 

The so-called strumous children are exceedingly likely to suffer from 
eczema, especially of the impetiginous type. The scalp, face, and backs of the 
ears are most likely to be affected : there is much oozing of a semipurulent 
fluid, which dries and forms yellow crusts. The lymphatic glands asso- 
ciated with the seat of the eruption are apt to become enlarged, and sub- 
cutaneous abscesses to form. 

It is a popular notion that many of the eczemas of infancy are due to 
teething, and that a chronic eczema is always worse when a tooth is being 
cut. Mothers often look forward to the last teeth being cut, as they believe 
that then the child will be free from eczema. In all this we think there is a 
great deal of exaggeration, but it is easy to understand that a swollen and 
tender gum may give rise to a good deal of crying, and some feverishness, 
and so any eczema, especially affecting the face, may be aggravated. It is 



782 Diseases of the Skin 

perhaps necessary to emphasize the important part which scratching plays in 
producing eczemas in infants and in preventing healing. 

Vaccination is frequently blamed by the parents of eczematous children : 
it is certain that a local eczema may arise at the seat of the vesicles, and an 
impetigo be started elsewhere in consequence of scratching and inoculation 
of infective pus into healthy skin ; but we do not think that vaccination gives 
rise to a general eczema. 

What part do micro-organisms play in producing eczema? It is quite 
certain that many cocci may be found in every eczema, but it hardly can be 
said that they are the cause of eczema in the same sense that the tubercle 
bacilli are the cause of lupus or phthisis. Given a papular itching eczema, 
then scratching removes the cuticle and inoculates the broken skin with 
cocci, which find a congenial soil in which to flourish. Much of the chronic 
inflammation which follows is doubtless the result of the growth of the cocci 
thus inoculated. Eczema may be self-inoculated, like true impetigo, by 
scratching. A tendency to eczema is hereditary. 

Symptoms and Course. — The commonest places for eczema in infants and 
young children (local irritants excluded) are the forehead, cheeks, scalp, and 
backs of the ears. The limbs, especially the flexures of the joints and backs 
of the hands, are often attacked. The usual form is eczema vesiculosum ; 
in weakly and scrofulous children the pustular variety, E. pustulosum or 
impetiginodes, is the most common. The former mostly begins with patches 
of redness, the inflamed patch quickly becoming the seat of numerous 
papules ; in less severe cases the papules may make their appearance in crops 
on apparently normal skin. In the worst cases the itching is intense, and 
the skin of the forehead or cheeks is hot, red, and cedematous. The papules 
quickly become vesicular and burst, or perhaps more often the inflamed skin 
begins to ooze without distinct vesicles being formed. A free discharge 
from the skin usually gives relief. The skin continues to weep, perhaps 
for some days, and probably also the eczematous patch is extending, cover- 
ing the whole forehead and affecting the cheeks, so that at this period all 
stages of the affection may be seen. In one place there may be redness 
only, in other places excoriated and weeping skin ; at another place the dis- 
charge has dried, forming crusts with raw, tender skin beneath ; where the 
eczema is nearly well the skin is thickened and the cutis desquamating. 
The skin of the thighs, flexures of the groin and knees, the arms and back, 
are very likely to become affected, and as the eczema heals in one place it 
is very likely to break out in another. Sooner or later the eczema passes 
into the subacute or chronic stage ; the skin is more or less red and indu- 
rated, there is less oozing from the surface, while there is a tendency to form 
crusts and for free desquamation to take place from the skin. This 
desquamation or scurfiness is particularly noticed on the scalp. 

In some cases the eczema is more of the erythematous type. The child 
goes to bed at night, and when warm in bed the face and forehead flush up, 
the skin becoming red, shiny, and hot ; the itching and tingling is intense, 
so that the child scratches and almost tears itself in its restlessness and dis- 
comfort, while sleep is out of the question. In the course of an hour or two 
the congested vessels are relieved by a serous discharge through the perhaps 
already damaged skin, and the inflammatory stage is succeeded by the 



Eczema 783 

oozing and crusting stage. The raw and tender skin left after the discharge 
more or less recovers and dries up, and then there is another inflammatory 
attack and the process is repeated. 

In weakly and scrofulous children the eczema is of a less acute type ; 
there is less redness, burning, and itching, and a greater tendency to pus for- 
mation than when eczema occurs in strong and healthy children. The scalp 
and face are mostly affected : in these places much crusting takes place, the 
crusts being formed of dried pus, and on raising these more or less puriform 
fluid escapes. In the early stages pustules are usually present. In the 
worst cases the whole scalp is a mass of thick crusts, abscesses form in the 
scalp, glandular abscesses are present in the cervical glands, and perhaps 
' cold abscesses ' in various places throughout the body. In dispensary 
practice an eczema pustulosum of the back part of the scalp is almost 
certainly the result of pediculi. 

All forms of eczema in infants and young children are apt to relapse, 
fresh attacks coming on before the skin has entirely recovered from the 
effects of the last attack, and the old place is soon as bad as ever. The 
tendency is for the attacks to involve the same places time after time where 
the skin has been injured or has ' contracted a bad habit.' Often, however, 
while healing in one place it breaks out in another. The younger the infant, 
the more troublesome is the eczema ; the older it grows, the less likely it is 
to relapse. 

The eczemas, or perhaps more properly erythemas, caused by the con- 
tact of foul napkins, or by two surfaces of skin coming in contact (intertrigo), 
are exceedingly common in dispensary practice ; with ordinary care they 
never occur in healthy children, but in infants suffering from intestinal 
catarrh or diarrhoea, where the napkins are constantly soaked with the 
excretions, a certain amount of soreness may be difficult to avoid. The skin 
is usually at first red, the erythematous eruptions spreading from the anus and 
genitals ; then the horny layers of the skin become detached, leaving superficial 
excoriations, from which serum and perhaps blood may ooze. 

Eczema in older children does not differ from eczema in adults. Any 
part of the body may be affected — the face, trunk, or limbs, and especially 
the flexures of the joints. A subacute or chronic conjunctivitis is commonly 
associated with eczema of the face. The skin readily becomes red and in- 
filtrated, with a dry, rough surface, which readily cracks, making painful sores. 
The itching is usually severe, and the affected part is constantly fretted and 
irritated by the scratching which goes on. 

Children who suffer from eczema are usually constipated. 
Complications. — Children who suffer from eczema may also be the subjects 
of bronchial asthma. In some cases the two diseases are co-existent, in 
other cases they alternate ; there is no constant rule as far as we have 
been able to determine. Eczematous children frequently also suffer from 
gastro-intestinal catarrh. This is only another way of saying that there are 
children who are specially prone to catarrh of the bronchial tubes, catarrh 
of the stomach and bowels, and also to a catarrhal inflammation of the 
external surface of the body. We have already remarked that eczema and 
impetigo may co-exist in the same subject, and so also may seborrhcea. 

It is well known that at times infants who are suffering from eczema, 



784 Diseases of the Skin 

especially when extensive, suddenly develop a high temperature, convulsions, 
and coma, and die in a few hours. We have seen this occur both in infants 
in hospital and in private practice, and do not doubt that there has been 
some connection between the eczema and the convulsion-fever. These cases 
are well known to the old practitioner, who regarded the fever, &c.,as the result 
of curing the eczema. This view is certainly open to doubt, and need not 
deter us from using our best endeavours to cure the disease. It is well, 
however, to bear in mind that a sudden and fatal illness may occur at any 
stage of the disease. 

Treatment. — The most scrupulous care must be taken to keep the healthy 
infant's skin clean, especially those parts which come in contact with the 
soiled napkins. A daily bath should be given from the first week, but a 
prolonged immersion must be avoided as likely to macerate and soften the 
cuticle too much. A good curd soap free from excess of alkali should be 
used, 1 and soft water in preference to hard. Some starch powder, such as 
finely ground rice or maize powder, with 20 per cent, of boric acid, should 
be applied after careful drying. 

If the parts about the genitals become red or excoriated, attention must 
at once be directed to the state of the infant's digestive organs to see if 
gastric and intestinal digestion is in a normal state, or if there is diarrhoea ; 
and it will probably be found that something is wrong here. The affected 
parts must be kept clean, as little friction as possible being used, and thin 
gruel, or rice boiled in milk, being used instead of soap ; or the parts may 
be cleansed with a piece of absorbent cotton-wool dipped in carron oil. 
(Lime water and linseed oil in equal parts.) After careful drying, boric 
acid powder, or oxide of zinc and starch (1-5), kaolin, or finely prepared 
fuller's earth, may be used to dust on. Where there is constant diarrhoea 
the ordinary napkin may be dispensed with, and pads made of absorbent 
cotton or wood-wool used instead, as they more readily absorb the faeces 
and urine. Unna's ' powder-bags ' are sometimes useful ; these are bags 
made of soft fine muslin, and filled with some dusting powder, as zinc 
and starch, or Taylor's cimolite, and quilted, to prevent the powder from 
gravitating to one end. These bags may be made ready and used as re- 
quired ; their value consists in keeping the parts dusted by the powder, 
which escapes through the pores of the linen or muslin. 

The dietetic treatment of general eczema is often difficult, as it may be 
by no means clear that anything is wrong with the digestive organs. If the 
infant is being nursed at the breast, great care should be exercised by the 
mother as regards her diet : beer, tea, coffee, salt meats or greasy dishes, are 
best avoided, or taken only in moderate quantities, while milk, fish, fresh 
meat, and vegetables may be taken freely. The infant, if vigorous and full- 
blooded, is perhaps taking too much breast-milk, and the amount should 
be lessened. Possibly the breast-milk may be poor in quality — containing 
an excess of sugar, while deficient in proteids and fat— and the infant is flabby, 
poorly nourished, and suffers in consequence from impetigo or intertrigo ; in 
which case some form of artificial food must be given in addition to the breast- 
milk. In artificially reared children the question of diet is of great importance : 



Unna's ' over-fatty ' soap or ' Vinolia ' soap makes a good soap for infants. 



Treatment of Eczema 78$ 

eczematous infants being brought up on cow's milk are frequently constipated 
and pass large quantities of undigested curd in their stools. In such cases 
some form of modified or humanised milk or whey should be given. In 
older children, especially if there is an excess of fat, starchy and saccharine 
foods should be avoided, and the diet confined as much as possible to milk, 
cream, eggs, broth, underdone minced meat, and green vegetables, 

The medicinal treatment must be directed to overcoming the constipation 
so often present, and exciting the action of the liver ; small doses of mercury, 
euonymin, or rhubarb and soda may be prescribed. (F. 95 or 96.) Small 
doses of Rubinat or Hunyadi water are often successful. 

Of other internal remedies in the acute stages, alkalis, such as the citrate 
or bicarbonate of potass, with nux vomica, are frequently useful. Effervescing 
citrate of potass and lithia is useful, acting both on the bowels and kidneys. 
Carlsbad salts, taken in warm water before breakfast several times a week, 
may be prescribed in older children. Arsenic is rarely, if ever, of use in 
the early stages of infantile eczema ; indeed, we have seen cases which 
were made distinctly worse by it. In many cases in infants a dose of two or 
three grains of choral hydrate (infant six months) will secure a good night 
and prevent scratching. In older children in the chronic stages, where there 
is a disposition to excessive desquamation, arsenic is usually beneficial. In 
the chronic impetiginous eczemas of scrofulous children cod-liver oil and the 
iodides may be prescribed with great advantage. Cod-liver oil and arsenic 
may be given, or arsenic can be added to some ready-made cod-liver oil 
emulsion. (F. 97.) 

In the management of local remedies much depends upon how the 
application is used, and much time and trouble may be well bestowed in 
showing the friends of patients how to apply the dressings, and, what is by 
no means easy, to keep them in position. Merely smearing on an ointment 
or dabbing on a lotion may be an entirely valueless proceeding ; moreover, 
the newly formed cutis is very easily injured. The ointment or lotion re- 
quires to be kept in constant contact with the part if it is to be of any use. 
In infants and young children some method will have to be adopted to 
prevent scratching ; mittens must be placed on the hands, and in some cases 
it may be necessary to secure the arms by means of bandages. 

For application locally the range of remedies is very wide, and various 
combinations have been called into requisition in the way of lotions, 
liniments, and ointments. As a rule, in all acute eczemas, where there is 
much excoriation of the skin, or thin newly formed skin is present, much 
washing or rough handling should be avoided. On the other hand, in 
chronic cases, where the skin is thick, scaly, or infiltrated, baths are of great 
service in removing the scales and softening the skin. In all eczemas, how- 
ever, a certain amount of cleansing is necessary to remove the remains of 
the old ointments and crusts : this can usually be done by gently applying 
some almond oil — or carron oil answers very well — ordinary soap being best 
avoided in acute cases. 

In all acute or subacute eczemas soothing remedies are required, and 
must be persevered in as long as there is an irritable condition of the skin 
and free discharge. The most troublesome eczemas in infancy are those of 
the face. In these, when the skin flushes up and is hot and angry during 

3E 



786 Diseases of tJie Skin 

the evening exacerbation, and the infant sleepless and restless from the 
burning and itching of the skin, hot poppy-head or boric fomentations often 
give relief. Perhaps more often cooling applications are the most grateful, 
and for this purpose carron oil, with or without ichthyol, may be applied on 
lint and kept in place with a bandage. (F. 98, 99, 100.) 

When the eczema has passed into the scaly stage, and there is no large 
amount of discharge from the skin, more stimulating ointments may be used 
and the face kept continuously bound up to exclude the air. There should 
be a daily cleansing with carron oil to remove the excess of ointment and 
the accumulated scabs, and now Lassar's or Ihle's pastes are useful to forma 
protective covering to tne newly formed skin, but they are difficult to remove 
if allowed to cake on to any extent. (F. 103, 104.) 

In acute general eczema, where large surfaces of the body are affected, 
liniments applied on rag or lint should be used, and the parts firmly 
bandaged with gauze bandages so that the application may be kept in constant 
contact with the skin. When there is much discharge and the skin inflamed 
and tender, it is sometimes best simply to powder on some finely ground 
boric acid and surround the limb with absorbent wool, firmly bandaged 
on ; or strips of lint may be saturated with carron oil or calamine liniment. 
(F. 98, 99.) In a later stage, when the skin is thickened and scaly, with 
but little or no discharge, more stimulating applications containing sulphur, 
ichthyol, zinc, or lead are usually prescribed. (F. 102, 108.) The ointment 
should be of tolerably firm consistence, so as not to melt too readily and run 
into the lint. Ung. paraffini B.P. is one of the best. Mercurial ointments 
should not be applied to an extensive surface of skin or too continuously 
for fear of mercurial poisoning. 

In impetigo, where the discharge is more or less purulent and much 
scabbing takes place, the scabs should be removed by poultices or carbolic 
oil, and some diluted mercurial ointment (F. 106, 109) — or an ointment 
consisting of five or ten grs. of iodoform to the ounce — may be applied. 

Eczema affecting the scalp must be treated in a similar manner to that of 
the face, except that, as a rule, more stimulating applications may be applied. 
In the weeping and irritable stage carron oil or the calamine liniment or 
zinc and cold cream may be applied on lint or rags, and a nightcap worn by 
the child to protect the parts and prevent the infant from scratching. The 
hair must be kept short and the scalp cleansed every morning with some 
mild soap and warm water ; or thin gruel may be used. In the more chronic 
stages, especially in neglected cases, the crusts must be removed by oiling 
and poulticing, and some diluted white precipitate ointment or other mild 
mercurial ointment applied. Lassar's or Ihle's paste (F. 103, 104) may be 
used, being put on thickly, and the head covered with a cap made of old 
linen, or what is known as ' butter-cloth ; ' the crusts and excess of ointment 
must be removed daily or every few days. Eczema of the scalp, the result 
of pediculi, should be treated by poulticing, cutting the hair, and the 
continuous application of white precipitate ointment. 

In the chronic general eczemas of older children, especially where the 
skin is rough and coarse, and there is much infiltration, and the flexures of 
the joints are affected, baths and stimulating liniments, followed by some 
soothing protective ointment, usually answer best. Soft soap, the pure 



Treatment of Eczema 787 

green variety, may be rubbed over the parts on a wetted flannel for a minute 
or two so as to soften the skin ; it is then washed off in a warm bath, the 
child dried, and some strips of lint coated with zinc and lead ointment 
applied. This plan answers well in hospital, but the application of the soft 
soap causes smarting, and in private practice the child's friends are apt to 
think it makes the eczema worse and fail to persevere. Instead of the soft 
soap, the old ointment having been cleaned off, the parts may be sponged 
with lead and carbolic lotion (F. 107) every evening for a few minutes, 
and this treatment should be followed by simple zinc or lead ointment. 

In local eczemas, especially those about the nose, back of the ears, and 
flexures of the joints, Unna's salve plaisters or salve muslins are very con- 
venient and efficacious. Pieces of these can be cut with the scissors to any 
shape, and when placed over the patch of eczema can be readily held in 
position by a light bandage. The zinc and red oxide of mercury salve 
muslin and tar and lead are the most useful. 

Impetigo Contagiosa, Staphylococcia. — This eruption is charac- 
terised by the formation of crops of vesicles of various sizes, which become 
converted into pustules. The pustules dry up or become ruptured, leaving 
a greenish-yellow thick scab. The eruption is most common about the face, 
especially round the mouth ; it may also occur about the neck, hands, and 
feet. In some cases there is marked febrile disturbance before the vesicles 
appear. When the patient is seen for the first time, after having been 
affected for several days or a week, but few vesicles may be present, and 
only scabs and crusts visible on the face and back of the neck. Deep 
ulcers may form at the seat of the pustules. The disease, as its name 
implies, is contagious, being transferred by means of the nails from one part 
of the body to another, and from one child to another in a similar way. The 
attacks may be acute in character, and the constitutional disturbance severe. 
It occurs in cachectic children and is rarely seen except in hospital practice. 
It may follow midge bites. There is a close resemblance between impetigo 
contagiosa and some forms of eczema. Indeed we should say clinically 
there is no sharp line of demarcation between them. The treatment con- 
sists in removing the scabs by oiling or poulticing, and applying dilute 
white precipitate or sulphur ointment on lint. Cod-liver oil should be 
given internally. 

Seborrhoea. — Seborrhcea is a 'functional disorder of the sebaceous glands, 
producing' increase of the secretion, which forms an oily, waxy, or scaly 
accumulation on the surface.' (Crocker.) 

The most familiar example of this disorder is seen in dispensary practice 
in infants who are badly looked after and rarely washed ; in such there is often 
an accumulation of a dirty yellow material over the anterior fontanelle, which 
can be scraped off with a blunt instrument. A certain amount of eczema 
may be present. What has been termed ' dry seborrhcea ' is not uncommon 
in the scalp of older children ; it may occur also on the face as well as on 
the trunk and limbs ; the scalp is dry and covered with small scales or scurf, 
which fly out when the head is combed or brushed. Care must be taken 
not to mistake diffused ringworm of the scalp for simple seborrhcea. 

Treatment. — The excessive sebaceous secretion on the scalp of infants 
can usually be removed by gentle friction with a piece of flannel dipped in 

3 E 2 



788 Diseases of tJic Skin 

warm olive or almond oil, following this up with washing with soap and 
water ; this process may want repeating once or twice, and care must be 
taken to keep the child's head well washed. If there is a tendency to exces- 
sive secretion, a little ung. hydrarg. ox. flav. (5 per cent, in vaseline) or ung. 
boracis (5ss ad 3J benzoated lard) should be applied. For dry scaly patches 
on the face an ointment consisting of precipitated sulphur in cold cream (5ss 
ad 3J) may be used. 

Erythematous Eruptions. — The term ' erythema ' is applied to those 
eruptions which consist in a redness or congestion of a more or less extended 
portion of skin, as well as to other eruptions, where there is not only a con- 
gestion, but an actual exudation from the cutaneous vessels, as in erythema 
nodosum. 

A simple erythema or congested portion of skin occurs under various 
conditions ; it may be the result of some external irritation, such as the con- 
tact of foul napkins ; the application of various irritants, such as mustard, 
chrysarobin, arsenic ; or the bites of insects. An erythema sometimes pre- 
cedes the eruptions of the specific fevers : this occurs at times in srnall-pox, 
chicken-pox, vaccinia ; and it accompanies other febrile disorders, which are 
not usually accompanied by a rash, as diphtheria, cholera, and septicaemia. 
An erythematous redness is often present when there is a high temperature, 
as in pneumonia and other febrile disorders. An idiopathic erythema 
or roseola is not uncommon in infants and young children, mostly as 
the result of some intestinal irritation, possibly also due to the iritation of 
the gum caused by dentition. It is more or less patchy in its distribution, 
occurring on the forehead, face, trunk, or limbs ; there may be no marked 
constitutional disturbance, and the patches of redness may be the first 
symptom. In other cases there may be several degrees of fever, restless- 
ness, and perhaps vomiting. The eruption is mostly fugitive, disappear- 
ing in a few hours to twenty-four hours. Other patches may appear as the 
first ones fade. 

Erythema Scarlatiniforme. — Is a typical ' scarlet fever rash ' ever 
present in any non-scarlatinal case ? It is difficult to answer this question 
dogmatically, but it may certainly be said that in any case when there is a 
diffuse, well-marked, punctiform rash, remaining visible for at least twenty- 
four hours, the disease is almost certainly scarlet fever or rubella. It is 
certain, however, that some erythematous or roseolous rashes do closely 
resemble scarlet fever, and, as they are attended not infrequently with some 
constitutional disturbance and fever, the difficulty in diagnosis may be very 
great. 

Some children are especially liable to roseolous rashes resembling scarlet 
fever, as the result of indigestion or some other source of irritation ; a roseo- 
lous rash is also apt to occur in septic conditions, such as in an empyema, or 
wherever pus is shut up in a cavity. 

The constitutional disturbance in these cases is generally slight ; the 
temperature may reach 101 or 102 F., the tongue may be slightly coated, 
but the child usually feels quite well and his appetite is normal. The rash 
may very closely resemble mild scarlet fever ; it is, however, as far as our 
experience goes, never so intense as it is in a typical or well-marked case of 
scarlet fever ; moreover, in some part of the body it is almost sure to be 



Erythema Scarlatiniforme 789 

patchy and unlike scarlet fever. The distinction between a roseolous and a 
scarlet-fever rash may be difficult or impossible if one part of the body only 
happens to be seen, but the difficulty usually disappears if a careful examina- 
tion of the whole body be made, as in some places, especially the face and 
trunk, the roseola is patchy, the patches having" a sharp outline. Crocker 
speaks of a roseolous rash lasting two to six days, and followed by a more or 
less copious desquamation. We have never seen such a case, and should be 
extremely suspicious of scarlet fever in such cases. In our experience an 
erythematous or roseolous rash, while it may closely resemble a scarlet-fever 
eruption, is more fugitive, and rarely lasts more than twenty-four or forty- 
eight hours, and is not followed by desquamation. In the majority of cases 
the presence or absence of a tonsillitis will decide the diagnosis. 

A roseolous rash may follow the taking of certain drugs, more especially 
belladonna, copaiba, and salicylic acid. 

Erythema Pernio, Chilblains. — Children with slow circulations, 
especially the so-called strumous, are very apt to suffer from chilblains. The 
favourite spots are the toes, heel, and fingers ; they begin with redness and 
intense itching, or aching, coming on towards evening, or when the patient 
is warm. The skin is smooth, livid, and shiny, and ulceration may take 
place if it is subjected to much friction. Children subject to chilblains should 
wear warm woollen stockings and well-fitting boots with broad toes and 
thick soles, and should take much exercise. In the early stages the affected 
parts may be painted with equal parts of tr. iodi and lin. aconiti, or lin. 
saponis co. with an equal quantity of lin. belladonnas. A mild capsicum 
ointment also answers well (capsici 5ss, almond oil 5y? lanoline 5yj), rubbed 
in with a piece of flannel. Zinc ointment with ung. hydrarg. ox. rubri, or 
ung. picis liq., in varying proportion according to the stimulating effect desired, 
may be applied. 

Erythema Multiforme is mostly seen during early life in association 
with rheumatism, or in rheumatic subjects ; whatever importance it possesses 
is derived from this association. The outbreak of this form of erythema is 
always suggestive of the rheumatic state, and an examination of the heart 
or endocarditis should always be made. The most common form consists 
in red papules surrounded by more or less congested skin. In association 
with the papules there may be flat raised patches surrounded by a zone of 
redness (erythema marginatum). Sometimes the eruption becomes purpuric, 
and bulla? or vesicles may form. 

Erythema Nodosum has apparently a close relationship to the erythema 
just described, though the constitutional disturbance is often much greater. 
Prior to the appearance of the nodes there may be rheumatic pains and fever, 
the temperature perhaps reaching 103 or 104 , and the child is apparently 
quite ill (see fig. 48). The eruption appears most copiously over the shins, 
but the arms, especially on the extensor surfaces, or any part of the body, may 
be attacked ; it appears as node-like, tender, red swellings of various sizes, 
accompanied by a burning or itching sensation. The patches come out two 
or three at a time in various parts of the body. At first rose-red in 
colour, they then assume a darker-red colour, and as they disappear become 
of a yellow colour like a fading bruise. 

Not much treatment is required for erythema multiforme or nodosum 



79° Diseases of the Skin 

A light milk diet, a mild aperient with some saline, with salicylate of soda if 
rheumatism is suspected. Locally, lead lotion with some tr. opii or liq. car- 
bonis detergens may be used. 

Urticaria is characterised by the sudden appearance of elevated blotches 
or wheals, at first red in colour, afterwards becoming white and sur- 
rounded by a zone of redness. They are attended by much burning and 
itching. The blotches usually disappear in the course of a few hours, but 
most frequently there are successive crops. In some cases a certain 
amount of oedema is produced by urticaria ; we have seen children with 
oedema of the eyes and backs of the hands following nettle-rash. There is 
usually some gastro-intestinal disturbance. Urticaria is sometimes, espe- 
cially in infants, a distressing and troublesome complaint, the intense itching- 
making the child restless, and entirely preventing sleep. Urticaria is the 
result, in the large majority of instances, of some irritation in the alimentary 
canal, less often of teething ; sometimes it is due to the bites of insects 
or scabies. Worms are not an uncommon cause in young children ; fruits 
of various kinds, especially strawberries, fish, sausages, stale meat, sour 
milk, or any kind of fruit which disagrees, may act as a cause. 

The most troublesome form of urticaria is that variety known as urticaria 
papulosa or lichen urticatus. This is a very intractable affection and 
may last for many months or even years. When seen in dispensary practice 
it is very apt to be mistaken for scabies, as the rash consists of numerous 
papules ; many are often scabbed over as the result of scratchings about the 
body, limbs, hands, and feet. In the worst cases the whole body is covered 
with itching papules, which in some places perhaps become pustular, making 
the resemblance to scabies a very close one, but no ' burrows ' can be dis- 
covered. The eruption begins as small wheals, which become papules, 
fresh ones coming out every night in crops when the child goes to bed. 
Rest is broken, and health may be seriously interfered with. It is most 
common during the period of the first dentition, and the tendency to it 
mostly disappears at three or four years of age. In the milder cases there 
is a succession of papules, some of which are surmounted by a small vesicle, 
which is quickly broken by scratching. After two or three days the rash 
ceases to make its appearance, to return perhaps in a few weeks. Gene- 
rally speaking, urticaria is more common in summer than winter. 

In some children fleas and other insects will produce vesicles as w r ell as 
papules, and give rise to more or less constitutional disturbance. 

Treatment. — An aperient should be given, calomel or rhubarb and soda 
being the best. Santonin and calomel maybe given if worms are suspected. 
A saline such as citrate of potash or bromide of potassium may be ordered. 
Locally, sponging the wheals with lead and tar lotion (such as F. 107) is 
perhaps the best application, or each wheal may be rubbed with menthol or 
painted with collodion. Sulphur baths (sulphuret of potassium, Jij to a bath) 
are useful in the chronic varieties. 

Iiichen Scrofulosus 'is characterised by very small inflammatory papules 
of a red colour, fading to that of the normal skin, disposed in groups or circles, 
and occurring mainly in scrofulous subjects.' (Crocker.) 

This form of lichen is not common in our experience, but it is easily 
overlooked, inasmuch as it is unattended with any great inconvenience to the 



Liclien Scrofulosus 791 

patients : they may make no complaint, and it is only discovered accidentally. 
The important points in the diagnosis consist in the absence of irritation 
and the presence of caseous lymph glands or other well-marked evidence of 
scrofula. The papules are small, and of a bright red colour at first, gradually 
changing to dull red, then desquamating, and finally leaving a brown stain. 
They must be present on the trunk or limbs. Their course is very chronic, 
fresh papules appearing as the old ones fade, so that the patient may not be 
entirely free for months or years. 

Psoriasis. — This affection is common in children over three years of 
age, but is seldom so severe or so intractable as it often is in adults. It is 
perhaps even more liable to recur in children than in adults. The symptoms 
are so similar during childhood to those seen in after life that no detailed 
description is necessary. The treatment we usually adopt is to give arsenic, 
beginning with two-minim doses and gradually increasing it ; warm baths, 
with the moderate use of green soft soap to remove the scales, and the 
application of some tarry or mercurial ointment. In hospital patients we 
have used Auspitz's solution of chrysarobin with great success. The solution 
is applied to the spots twice a week, a patient wearing old linen to avoid 
damage. (F. 109, no.) 

Pityriasis Rubra. — We have occasionally seen this disease in children, 
but it is comparatively rare. The best marked case was in a girl of eight 
years who was in hospital twice with a precisely similar attack. The rash 
appeared to commence on the chest, and spread over the arms, trunk, and 
extremities. It consisted of a red rash covered with fine thin scales. Both 
attacks proved very chronic. A lotion of bichloride of mercury (1-5000) was 
used, but had to be stopped on account of salivation. 

Miliaria. Sudamina. — In various fevers, such as scarlet fever, enterica, 
and in other febrile disorders, as rheumatism, a number of minute vesicles 
with clear contents make their appearance on the skin. The clear fluid is 
sweat, which has been unable to escape from the orifice of the sweat gland ; 
the contents of the vesicles are absorbed or dried up in a day or two, leaving 
a tiny desquamating spot. In other cases a slight inflammation occurs at 
the blocked sweat gland, and a minute papule appears instead of the vesicle, 
though vesicles may also be present ; this condition has been called Miliaria 
rubra. The so-called lichen strophulus or ' red g-um ' is, according to 
Crocker, a sweat rash ; it consists of minute crops of red papules which 
make their appearance in infants ; they are attended often with much itch- 
ing and consequent restlessness of the infant. A somewhat similar rash has 
been attributed to dentition as well as to gastric irritation. The papules 
should be dabbed with the lotion F. 99 or F. 100, and powdered with boric 
acid or some drying dusting powder. 

Pemphigus is rare in infants apart from syphilis, but attacks of the 
acuter form of the disease [Pemphigus neonatorum), occurring in epidemics 
in lying-in hospitals or in the practice of a midwife, have been recorded by 
continental writers. In these cases the disease appears to have been dis- 
tinctly contagious : not only has it apparently passed from infant to infant, 
but also from infant to nurse. In a few cases the eruption is preceded by 
fever, restlessness, or convulsions ; the rash usually appears at the end of 
the first week. The bullas vary in size : their contents are clear or slightly 



79 2 Diseases of the Skin 

cloudy, rarely pustular ; they gradually dry up, forming superficial ulcers or 
crusts. All parts of the body may be attacked, and, unlike syphilitic pem- 
phigus, there is no preference for the palms of the hands or soles of the feet. 

Chronic pemphigus is seen occasionally in older children ; in some of 
these cases the children appear to be in good health and complain of nothing 
except the eruption, for which no cause can be assigned. In most cases 
there is marked anaemia, and more or less fever and constitutional dis- 
turbance ; the latter may be severe. The number of bullae varies from two 
or three to perhaps twenty ; they appear as vesicles on the face, trunk, and 
limbs, gradually enlarging, and finally drying up in the course of a few days. 
The treatment consists in giving arsenic in full doses, and cod-liver oil. 
Locally, boric acid or zinc ointment may be applied. In trie severer cases 
continuous baths are useful. 

Dermatitis Gangrenosa Infantum. — In speaking of varicella we have 
referred to a peculiar form of multiple gangrene of the skin, which is apt to 
follow varicella in anaemic or emaciated children (pp. 307, 308). There is 
reason to believe that this condition is not necessarily preceded by varicella, 
but may follow other pustular eruptions (Crocker) ; it has been known also 
to follow vaccination. It almost always occurs in infants or young children 
under three years of age, and in many of the fatal cases tuberculosis has been 
found. In these cases the varicella vesicle or pustule is succeeded by an 
ulcer, which rapidly extends in size and depth, several frequently joining 
together, so as to form large sinuous ulcers ; the floor becomes black from 
the formation of sloughs. In the worst cases the scalp, face, body, and limbs 
are covered with sloughy-looking ulcers, either separate or confluent. There 
may be marked constitutional symptoms. In one of our cases there was 
recovery, the ulcers gradually healing up ; in the majority of cases a fatal 
result ensues. The treatment consists in giving the child a generous diet, 
including beef tea and wine, and dressing the ulcers with iodoform or other 
antiseptic ointment. 

Dermatitis Exfoliata Infantum. — It is not uncommon to find infants a 
few weeks old with a diffused red rash which desquamates freely, the skin 
coming off in scales or flakes. The skin is thickened, red and shiny, cracks 
or fissures appear round the lips, and in places large ulce-rs may form, 
especially over the sacrum. The disease usually begins during, the first 
week or two of life, the infant suffers from marasmus, with perhaps vomiting 
or diarrhoea. It is usually fatal. This disease is often mistaken for syphilis, 
especially as there may be some coryza and the eruption first make its 
appearance about the buttocks or ' napkin area.' It has, however, nothing 
to do with syphilis, but is probably a form of septicaemia. It apparently 
occurs most frequently in Foundling Asylums. In all the cases we have 
seen the infant has been artificially fed. 

Drug* Eruptions. — The most important rash belonging to this class is the 
Bromide eruption. In some children a few grains of a bromide salt are 
sufficient to cause a rash, while in other cases the salt may be taken for 
weeks or months together without giving rise to any eruption. Infants 
perhaps are more liable than older children. The eruption consists in most 
cases of a red papular rash, the papules being discrete and occurring chiefly 
on the face, scalp, trunk, and limbs. On the summit of the red papules are 



Ringworm of the Scalp 793 

one or more yellowish points, or small pustules. The rash looks more like 
acne than any other rash. It is sometimes confluent. Scabbing and ulcera- 
tion may take place. We have seen the scabs and ulcers an inch in 
diameter on the limbs. 

A somewhat similar rash also occurs after taking Iodides, but it is less 
common. Antipyrin and Phenacetin in some recorded cases have given 
rise to a ' measly ' eruption or an urticaria. We have several times noted a 
papular rash after giving antipyrin. The long administration of Arsenic is 
sometimes followed by a darkening of the skin, especially marked on the 
abdomen and trunk. The pigmentation mostly disappears after the drug is 
left off. Salicylic acid or the soda salt sometimes gives rise to a ' measly ' or 
urticarial rash. Belladonna may produce a roseolous rash (see Roseola). 

Tinea Tonsurans. — Ringworm of the scalp is one of the most trouble- 
some local diseases with which the practitioner has to deal, and one which 
is apt to bring unmerited discredit on account of the many months or even 
years that the disease sometimes lasts. In some children there seems to be 
an especial disposition of the disease to spread, and to relapse when to all 
appearance it has been cured, or, in spite of the local treatment vigorously 
carried out for months, no marked improvement ensues and every one con- 
cerned becomes tired of the case. 

Ringworm is exceedingly contagious, one child taking it from another in 
consequence of the spores of the tricophyton being transferred from one to 
another by direct contact, or by means of hair-brushes, combs, caps, or bed- 
linen being used both by the affected and the healthy. It rarely affects 
infants, or children after puberty, its subjects, especially in the chronic form, 
being the weakly rather than the strong, though exceptions may be met 
with. 

The disease when recent may be recognised at a glance : the patches are 
circular, the central skin in the smaller ones being red in colour, while at 
the circumference desquamation is freely going on, the branny scurf giving 
the patch at this part a greyish or yellowish appearance ; the hairs from the 
central part may have come away, or they have broken off, leaving stumps. 
In the larger patches all traces of redness have disappeared, and they are 
simply bald or scurfy patches of varying size. Chronic diffuse ringworm of 
the scalp, especially if it has undergone a certain amount of irritation as the 
result of treatment, is more difficult to diagnose ; there may be much scurfi- 
ness, perhaps scabbing and pustulation. In the condition known as kerion 
the hair follicles suppurate, the hairs becoming loosened at their roots, and 
there is redness and puffiness of the patch. The diagnosis of ringworm is 
made from the stumps of hair left after the hair has broken off. These are 
best seen by means of a lens of two or three inches focal length: the stumps 
will then be readily seen often more or less twisted or bent, and having lost 
the gloss ordinarily seen on the hair. They are readily extracted with for- 
ceps, as they are mostly loose in their follicles ; they can then be placed upon 
a glass slide with a drop of liq. potassas and examined after soaking for half 
an hour. The broken hair will be found to be frayed out at the end, and 
moreover infiltrated with conidia or spores ; the latter are readily seen with 
a power of 300 diameters if a sufficient time has been allowed for the caustic 
alkali to dissolve the fatty matters and render the hair transparent. The 



794 Diseases of the Skin 

mycelium is less readily seen than the spores. It is needless to say it is 
mostly useless to examine the unbroken hairs, and in old cases which have 
been treated no spores may be present in the scurf. The greatest caution 
must be exercised before pronouncing that a case is well, or certifying that 
it is no longer infectious, as relapses occur again and again, and may be the 
means of communicating the disease to others. Before any patient can be 
said to be cured, repeated examinations must be made with the aid of a 
lens for diseased hairs, any suspicious-looking stump being extracted and 
examined microscopically ; it is well to remember also that scurfy patches, 
even when the hair is growing freely over them, are extremely suspicious. 
In every case some mild parasiticide should be continued to be applied for 
some time after the disease appears to have been eradicated. In seborrhoea 
or non-parasitic scurfiness the whole scalp is affected, and, though the hair 
may come out, there are no broken stumps and no sharply defined patches 
of scurfiness as in ringworm.. 

The course of ringworm is apt to be exceedingly chronic, and when 
undertaking the treatment of a case it is well not to be too ready to name a 
definite time when it will be well. 

Tinea Circinata. — Ringworm of the body is frequently associated with 
ringworm of the scalp. It is first seen as a raised red spot, which becomes 
scaly at the periphery as it enlarges, while the centre may present more 
or less healthy skin ; as the ring enlarges it becomes more or less broken 
and fainter. It may be present on all parts of the body ; it is perhaps 
commonest on the face and neck. The diagnosis is generally easy, for though 
sometimes the patches of scurfiness on children's faces may be mistaken 
for ringworm, they do not assume the formation of a ring with a normal skin 
in the centre ; if any difficulty occurs, an examination of the scales scraped 
off the patch for spores would decide. 

Treatment. — The treatment of tinea circinata is a comparatively simple 
affair, and is readily effected by the continuous application of some mercurial 
ointment or solution for a few days or a week. It is well to commence 
treatment by removing the scales as far as possible with soap and water, and 
then some dilute white precipitate ointment may be gently rubbed into the 
patch morning and evening. An ointment containing sulphur, 5 SS > and ung. 
picis liq., 5j, to the ounce of benzoated lard also answers well. Carbolic oil 
or carbolic acid in glycerine (1-8) may be used. 

In the treatment of ringworm of the scalp the first step to be taken is to 
cut the whole hair off with a pair of scissors to at least half an inch, leaving 
a fringe if thought desirable ; the scalp can then be carefully examined, and 
it will be usually found that there is more extensive disease than was at first 
thought. Wherever there are any patches of ringworm the hair must be 
cut close to the scalp both over and around the patch. The scalp should be 
thoroughly washed with soft soap or carbolic soap, removing all or as many 
of the scales as possible. The ointment or application selected should then 
be rubbed in by means of a mop of rag for a few minutes, at least twice a 
day. Very many parasiticides have been recommended ; the one we have 
mostly used, and which is certainly as successful as any, is the oleate of 
mercury, and we fully endorse Dr. Alder Smith's praises of it. An oint- 
ment containing 5 per cent, is used for children under eight years of age, and 



Treatment of Tinea Circinata 795 

10 per cent, for older children ; a small piece of the ointment is rubbed 
vigorously into the affected patch every morning- and evening ; if there is 
much tenderness it must be omitted for a day or two. Once a week at least 
the ointment should be washed off with soft soap, and the effects of treat- 
ment carefully noted. Oleate of mercury is especially suited for the diffuse 
form of ringworm ; it apparently penetrates better than iodine or carbolic 
acid, which tend to harden the epithelial tissues ; this power of penetration 
is obviously of great advantage when the fungus extensively affects the 
hair- roots. 

In the early stages, when there is a single circumscribed patch of ring- 
worm or only a few patches, some more powerful remedy than the 5 per 
cent, oleate of mercury may be used with advantage. The 10 per cent, 
ointment may be applied, or carbolic acid and glycerine (1-6 by measure) 
may be rubbed into the patches night and morning. Coster's paint (iodine 
5ij, oil of cade 5 v j) ^ s 2L ^ so useful in recent cases painted on the patch, 
removing the crust every few days and re-applying. Glacial acetic acid and 
hydrarg. perchlorid. (gr. iv ad Jj) as used by Alder Smith are good appli- 
cations, as is also Auspitz's solution of chrysarobin in chloroform (F. no). 
The last two must only be used to circumscribed small patches, and are 
not suitable for young children or those in whom inflammation is readily 
set up. It is well to keep the rest of the scalp well oiled with carbolic oil 
when strong applications are being applied to some local patch. A light 
skull-cap should be worn to prevent the ointment smearing the bed linen at 
night. 

While in the chronic or diffuse forms we prefer mercurial preparations, 
yet some cases appear benefited by a change, or at any rate a change of 
ointment will sometimes work wonders in the eyes of the friends. An 
ointment containing equal quantities of carbolic acid (Calvert's No. 2), ung. 
hyd. nitr., and ung. sulphuris (Alder Smith), is a good and useful one ; or the 
formula (F. in) recommended by Jamieson. 

Whatever form of application is adopted, it is tolerably certain that much 
patience will have to be exercised before the disease can be pronounced 
cured. Weeks and even months may elapse, and while progress has been 
made perhaps scurfiness and diseased stumps can still be detected ; or, 
perhaps, while the disease appears eradicated in one place, it is spreading in 
another direction. 

Epilation is useful in all stages, but timid and young children are too 
nervous to submit to much being done in this way. In cases which have 
proved intractable and resisted all treatment for months a local patch of 
inflammation may be set up by means of croton oil. The usual method is 
to paint some croton oil on over a patch of half an inch to an inch in 
diameter, to repeat it the next day, and to follow it up by a poultice ; the 
patch becomes red and puffy, suppuration takes place about the hair 
follicles, and the hairs readily come out. To this boggy condition the term 
kerio?i is applied. It is important to apply this treatment to only small 
patches at a time. 

After the disease has been apparently cured it is well to continue for a 
time with some remedy containing a mild parasiticide. One of the formulae 
106, 108, or 112 usually answers for this purpose. 



yg6 Diseases of the Skin 

Alopecia Areata. — Alopecia consists of smooth, shining bald patches on 
the scalp. It occurs at all ages, both of childhood and adult life. Its cause 
is uncertain, though there is a consensus of opinion that it is not due to any 
fungus. In some cases it follows severe headaches, in others there is 
no known cause, though it occurs mostly in those who are below par and 
out of health. It may occur first in patches, and perhaps after a while- 
involve the whole scalp. It is extremely intractable, and little influenced by 
local or constitutional treatment. Cod-liver oil and tonics are usually given, 
and stimulating lotions, such as F. 114. 

Pavus. — Favus is not a common disease in this country, but is occasion- 
ally seen among out-patients at a children's hospital. It is known at once 
by the peculiar yellow cup-like depressions formed by the crusts, and by the 
peculiar ' mousy ' smell. These crusts can be raised from the scalp by means 
of a blunt knife, carrying the hairs with them, leaving the pitted skin, which, 
however, crusts over again in ten or twelve days. The favus crusts may be 
present on the body as well as on the scalp. The subjects of this disease are 
generally cachectic and have been ill fed. The fungus — achorion Schonleinii 
— closely resembles the tricophyton of ringworm, but the mycelium is more 
jointed, and the gonidia are more numerous and larger, though they vary 
much in size. 

The disease is very chronic, frequently lasting for years. The treatment 
consists in removing the crusts, applying parasiticides, and administering 
cod-liver oil and iron. 

Scabies. — Scabies is very common in infants and children in dispensary 
practice, and by no means unknown among the well-to-do classes of society. 
Among the former there is rarely any difficulty in diagnosis, as they usually 
do not present themselves till the disease is well marked and pustules have 
formed, while in private practice the diagnosis may be difficult when the disease 
is local, as, for instance, on the hands. In infants and young children scabies 
gives rise to more irritation than in adults, and in infants at the breast urticaria 
and erythema of a more or less severe nature may be frequently seen. In 
infants the hands may be quite free, while the face and legs or genitals may 
be affected. In cachectic or weakly children there are usually much crusting 
and many pustules, pus being transferred from one part to another by 
means of the finger-nails. The diagnosis is not usually difficult ; urticaria, 
simple eczema, and lichenous rashes may be mistaken for it. The presence of 
burrows, the irregular distribution of the vesicles and papules, as well as the 
intense itching, are the characteristic points. We have, however, sometimes 
been in doubt regarding the nature of itching rashes present only on the 
backs of the hands. A cure is readily effected by a hot bath with the copious 
use of soft soap, followed by sulphur or storax ointment ; the bath and 
ointment should be repeated for four or five nights in succession, and the 
clothes should be stoved. (F. 115, 116, 117.) 

Pediculosis. — The pediculus capitis is exceedingly common among the 
children of the poorer classes, and is by no means unknown in other 
quarters. The insect's bite produces intense itching of the scalp, more 
especially in the occipital region, and vigorous scratching takes place. As 
a result, more especially in the weakly and cachectic, scabs, crusts, and 
pustules form, and in many cases the occipital glands become enlarged and 



Pediculosis 797 

may suppurate. A diagnosis is readily made, by the presence of nits and 
also crusts and scabs in the occipital region. The hair should be cut short, 
the scalp thoroughly cleansed with hot water and carbolic soap, and white 
precipitate ointment applied. Liquid paraffin or spirits of wine are very 
efficacious, but the smell is disagreeable. 

Flea-bites. — The common flea produces by its bite a small wheal 
surrounded by a red area, with a central red spot. The central spot, as 
also the distribution of the eruption, will generally distinguish it from 
urticaria or other rashes. The bite in debilitated subjects becomes petechial. 
The itching and irritation produced by flea-bites cause great restlessness and 
fever at night. Some children are much more affected by flea-bites than 
others. Body-lice and bugs produce similar eruptions. Carbolic ointment 
(ten per cent.), lead and carbolic lotion, or diluted sp. ammon. aromat. are 
useful in allaying irritation. 

Midge-bites. — Midges mostly attack the exposed parts, such as the face, 
arms, and legs. They will, however, crawl up arm slieves, beneath the 
stockings and up the legs. In hot weather especially their bites give rise to 
large wheals, which may become vesicular or pustular. The irritation is 
worse at night, and much scratching takes place. If pustules follow the 
bites, an auto-infection perhaps takes place, and pustules make their 
appearance in various parts of the body. We have seen children on their 
return from their summer holidays with deep ulcers, pustules, and enlarged 
glands, the result of midge-bites. 

Harvest bug-. — Occasionally during holidays in the country children 
will suffer from the attacks of the 'harvest bug' (Leptus autumnalis). To 
the naked eye it is a small red point, which adheres to the skin and produces 
papules that itch greatly. It buries its head in the skin, and in this way 
produces great irritation. It may produce symptoms not unlike scabies, the 
feet and legs being first affected. Pustules, ulcers, and staphylococcia 
may result. A weak sulphur or mercurial ointment may be used. 

Simple Onychia in children may be looked upon as a variety of the 
subcuticular form of whitlow, in which the nail matrix is involved instead of 
the skin of the finger. It is usually the result of some slight injury such 
as nail-biting, running a splinter beneath the nail, or too close cutting 
of the nails. Early letting out of the matter and removal of foreign material, 
with subsequent warm water or lead lotion dressing, is all that is required. 
Occasionally suppuration goes on intractably beneath the nail, or recurs 
again and again after drying up ; in such cases the nail should be cut away 
over the inflamed spot, and the surface scraped clean, and some solid nitrate 
of silver applied. 

Onychia Maligna is a more formidable affection, nearly, if not quite, 
always due to injury of the finger-end. The whole nail matrix becomes 
inflamed, the end of the finger is swollen, congested, and bulbous, the nail 
becomes loosened, curled up, and blackened, and there is much burning pain ; 
a dirty, sero-sanguineous, often foul discharge comes away, and the mischief 
may go on for months if neglected, and even give rise to necrosis of the 
terminal phalanx and permanent distortion or destruction of the nail. The 
treatment we have hardly ever found to fail is dusting the raw surface over 
with powdered nitrate of lead night and morning for a few days ; the nail 



79$ 



Diseases of the Skin 



should be removed if the disease has involved anything more than the upper 
part of the matrix. We have often seen onychia of many months' standing 
get practically well in a week under this treatment. Occasionally it is neces- 
sary to scrape away the diseased tissue and remove a sequestrum, but this is 
quite exceptional. 

lupus. — Mention has already been made of superficial tuberculous 
ulceration of the skin {vide p. 241), but the special form known as lupus 
vulgaris needs a short notice here. The affection consists in the develop- 
ment of small circular deposits of inflammatory material in the thickness 
of the true skin. These deposits, known as ' lupus tubercles,' are found 
usually in patches which tend to spread by the formation of new tubercles at 
the margin of the patch. At first isolated, after a while the tubercles 
coalesce and break down, forming a larger or smaller superficially ulcerated 
patch, which is usually coated over with thick scabs or crusts. In earlier 
stages there is no obvious ulceration, and a thin pellicle covers over each 
'tubercle.' If allowed to spread, extensive destruction of the skin may 
occur, and the deeper structures are in certain cases attacked. It is, how- 
ever, very rare for lupus to penetrate through 
the deep fascia, and it probably never attacks 
bone. The most extensive destruction is usu- 
ally of the nose, where the whole of the lateral 
and alar cartilages may be eaten away, leaving 
a short, pinched, and shrunken organ. Almost 
any part of the body may be attacked, but the 
face is the favourite seat, and especially the 
tip and sides of the nose. Less often the 
disease attacks the mucous membrane of the 
lips, cheeks, and septum nasi, and we have 
seen the tonsil and soft palate involved by 
extension from a patch of lupus at the angle 
of the mouth. We have one case under our 
care in which the skin of the shoulder, arm, 
and also the buttock and thighs, is extensively 
involved. The disease has lasted some years. Chronic in its course, and 
intractable to any but very thorough treatment, lupus is one of the most 
troublesome of the skin diseases met with in tuberculous subjects, especially 
as great deformity and disfigurement are often produced by its ravages. 
On scraping out a 'lupus tubercle' a hollow or pit is seen in the thickness 
of the. dermis, while at the edge of the patch the superficial part of the skin 
is undermined. 

Treatment. — The general treatment is that of tuberculosis, cod-liver oil 
and arsenic being of especial value. Locally nothing is so effectual as 
thorough removal of the disease mechanically. It is best to give an 
anaesthetic, and thoroughly scrape away and dig out all the soft tissue with a 
sharp spoon. All the material that can be scraped away should be removed ; 
healthy skin will not break down under the use of a Volkmann's spoon. 
After the scraping the actual cautery or solid nitrate of silver, or, better still, 
powdered nitrate of lead, may be applied, but the mechanical removal is the 
most important part of the process. There is free bleeding at the time, but 




Fig. 206. —Hairy mole of the face 
and scalp. A large part of the 
patch was removed by the use of 
the actual cautery and nitric acid. 



Hairy and Pigmented Moles 799 

this speedily stops. The sore should be dressed with iodoform ointment, and 
a careful watch kept for the appearance of fresh tubercles, which should be at 
once attacked in the same way. The repeated application of powdered 
nitrate of lead has been very useful in our hands, both for lupus and other 
intractable tuberculous sores ; it is somewhat painful, but very effective. 
Injections of tuberculin have recently been employed with some success. 
Certainly in many cases there is a temporary improvement, but relapses are 
very apt to occur. 

Papilloma. — Warts are very commonly met with on children's hands, 
and often appear in crops. They frequently disappear spontaneously, but if 
they are troublesome may be readily cured by some caustic application, or 
better by the steady use of salicylic collodion. 

Hairy and Pigmented Moles occur congenitally, and sometimes cause 
great disfigurement, as in fig. 206. If small they may be treated by excision. 
If extensive the growth may be removed in sections by the application of 
the actual cautery or strong nitric acid, but it must be remembered that any 
of these methods necessarily leave a scar. Mere overgrowth of hair may 
be removed by electrolysis and epilation. 



8oo Injuries, Shock, Hemorrhage, &c. 



CHAPTER XXXIX 

INJURIES, SHOCK, HEMORRHAGE, &C. 

The various injuries met with in children can only be very briefly described 
here, and only those more or less peculiar to childhood will be mentioned. 

Injuries to the Head. — In young children it is not uncommon for one 
of the bones of the vault of the skull to be dinted or dinged in, and a well- 
marked but shallow saucer-like depression may be felt. Care must be taken 
to distinguish this lesion from cephalhematoma (vide p. 21 ). The symptoms 
of brain injury in such a case are usually those of concussion and often 
speedily pass off ; recovery usually takes place without any bad symptoms, 
and the depression in most instances gradually becomes obliterated by 
pressure from within and modelling of the bone. 

The treatment of such cases is simply rest and quiet ; no operation is 
called for. Sometimes, however, where the depression is more abrupt and 
marked symptoms of compression exist, especially if the fracture is com- 
pound, the general lines of treatment for such cases in adults must be 
followed. In children the rule, however, is not to operate unless the fracture 
is compound. 

Traumatic Cephalhydrocele is the name applied to a condition where 
there has been a simple fracture of the skull, with probably in all cases 
laceration of brain and laying open of one or other lateral ventricle. The 
fluid contained in the ventricle escapes beneath the scalp and forms a soft, 
fluctuating, usually pulsating swelling ; this is distinguished from haematoma 
in some cases by its later onset and steady increase. The swelling, how- 
ever, may appear immediately ; sometimes it is not found for some months 
after the injury ; in any doubtful case aspiration would settle the point. 

Cephalhydrocele is most often met with in children under two years old, 
but may occur as late as the twelfth year ; it is most common in the parietal 
region. We have seen several of these cases. There is often extensive 
absorption of bone after the injury, so that a considerable gap is left in the 
skull. Hydrocephalus not rarely ensues. 

Treatme?it, &^c. — Tapping appears to be of little use, 1 and pressure and 
quiet are the only treatment. A plastic operation has been proposed to close 
the aperture in the skull, and might possibly be advisable in any case that was 
clearly getting worse. 

The mortality is high : some 40 per cent, of the patients die ; in some 
instances temporary recovery takes place and meningitis develops later. 

1 Lucas, Guy's Repts. 1879 et seq. ; T. Smith, St. Barth.'s Repts. 1884. Erichsen, 
Southam, Godlee, Howard, and Conner have recorded cases ; also Golding Bird, Guy's 
Repts. 1889. Year Book of Treatment, 1895, p. 226. 



Injuries of the Chest, Abdomen, &c. 80 1 

Occasionally after compound fracture of the vault a free escape of 
similar fluid occurs, as in one case of our own : there was a compound de- 
pressed fracture of the frontal bone, which required elevation ; an abundant 
flow of clear fluid took place from the wound before operation ; the boy 
recovered without any bad symptom. 

Fracture of the Base of the Skull in children is a much less serious 
injury than in adults, and is often completely recovered from. Traumatic 
meningitis is rare in children, and they generally recover well from con- 
cussion and brain laceration. 

Dr. Allen (' Lancet,' October 24, 1885) has described a fracture disloca- 
tion of the atlas occurring in infants ; the lesion is marked by hyper-extension 
of the head and a liability to ' epileptic fits ' on attempts at extension or 
pressure downwards upon the head. The injury is probably inflicted during 
parturition. Vide also Guerin, ' Gaz. Medic.,' 185 1. 

Injuries of the Chest. — The only fact about chest injuries that is 
peculiar to childhood is that, in consequence of the flexibility of the chest - 
wall, visceral lesions without fracture of the ribs are not uncommon. When 
rupture of the lung occurs the laceration is usually in the neighbourhood of 
the root of the lung, and the usual complications— emphysema, hemothorax, 
and haemoptysis — are often present, though the last is less often seen, since 
young children rarely expectorate, and the blood is swallowed. 

Injuries of the Abdomen have no peculiar features ; if the immediate 
shock is recovered from, subsequent complications are rarely fatal unless 
from some severe visceral laceration. 

Fracture of the pelvis in childhood is less likely to be complicated by 
visceral injuries than in adults, since sub-periosteal fractures and separation 
of epiphyses take place in children. We have met with a case of fractured 
pelvis in which the urethra was separated from its normal position beneath 
the pubic arch and displaced backwards towards the anus, the injury 
occurring in a little girl. 

Rupture of the membranous or spongy urethra is not uncommonly met 
with in boys as a result of failing astride some projecting edge, e.g. the top 
of palings or of a gate, or the bough of a tree. The symptoms are pain and 
swelling in the perinaeum, escape of blood from the urethra, inability to pass 
urine, and distension of the bladder unless it has been recently emptied. 
A gentle attempt should at once be made to pass a catheter ; if this succeeds, 
the instrument should be tied in for three or four days and then changed ; 
after a week or ten days it is sufficient to pass a full-sized catheter daily. 
This is the orthodox treatment, but a traumatic stricture usually results, 
requiring the passage of instruments frequently throughout life. Extravasa- 
tion of urine often occurs either immediately or within a day or two of the 
accident, and necessitates free incisions into all the infiltrated parts. To 
avoid these misfortunes probably the best plan is, immediately after the 
accident, to cut down upon and suture together the ends of the torn urethra. 
This we have done with excellent results in adults, and, as a secondary 
operation, in a child. 

Injuries of the Limbs. — The peculiarities of injuries to the limb bones 
in children depend mainly upon two facts. 1. The bones of children are 
soft, contain relatively little earthy matter, and are therefore less brittle 

3 F 



802 Injuries^ Shock, J 'J hemorrhage ; &c. 

than those of adults. 2. The epiphyses are yet ununited, and the periosteum 
is thicker, more easily detached, and more freely supplied with blood than 
in older people. 

Creenstick Fractures. — A greenstick fracture is one where more or 
less of the thickness of a bone has bent and yielded instead of snapping 
across ; there is probably really always a fracture. Simple bending of bone 
without fracture is of doubtful occurrence, in health at least, though it may 
occur in rickets and osteomalacia. Many fractures in children are sub- 
periosteal, and to this fact and to the incompleteness of the fracture is due 
the absence of marked symptoms in many cases, so that fractures are not 
rarely overlooked ; indeed, deformity, obvious mobility, and crepitus may 
all be absent, and it is common enough to see a fractured clavicle of a 
week's or a fortnight's standing, or even longer, in which the first sign that 
attracted the parent's attention was the ' lump in the neck,' consisting of 
callus round the fractured ends. Hence, after any severe injury, each part and 
limb should be systematically searched, especially in very young children, 
for all probable injuries. The treatment of greenstick fractures is the same 
as for ordinary fractures, any displacement being at once forcibly reduced. 

Ununited Fractures. — Fractures in children usually unite well, and even 
in rickety patients non-union is rare. We have already mentioned cases of 
non-union in fracture after necrosis of the tibia and humerus. Occasionally 
one or more of the long bones is fractured at or shortly after birth, or even 
in utero, and in these cases non-union is not very rarely met with. It is a 
curious fact that such fractures have almost universally resisted all attempts 
to procure union when once the ends of the bones have become atrophied 
and a false joint has formed. Sir James Paget has pointed out this pecu- 
liarity. 1 In one of our patients we tried many methods before obtaining 
union, as will be seen below. 

Case. — John H., at six weeks old, was found to have a fracture of the leg, but it was 
not known how long it had existed. The mother had a fall two months before he was 
born. On admission there w r as an old ununited fracture of both bones of the right leg 
15 inch above the ankle ; the limb was loose and almost flail-like. In May 1889 the 
ends of the bones were resected, and the tibia wired ; no union followed. He was re- 
admitted in July and plaster of Paris re-applied. In October the ends, which were much 
atrophied, were again resected, and ten pieces of bone, taken from the femur of a freshly 
killed young rabbit, were grafted in. The wound healed by primary union, and the limb 
was put up in plaster. No union nor even any formation of callus followed In January 
1890 the operation was repeated ; eight grafts being inserted, the wound was closed and 
the limb put up in plaster. Three pieces of the rabbit's bone were removed in April and 
May, and the wound healed. In June the wound was re-opened, and a long piece of rabbit's 
femur wedged in between the ends. The wound healed at once, and a good deal of thick- 
ening, but no real union, followed. In April 1891 the wound was re-opened and the large 
piece of rabbit's bone found bare and encysted in a cavity containing clear yellow fluid ; 
smaller pieces were found embedded in fibrous tissue ; there was no sign of any septic 
condition. The rabbit's bone was removed and the ends of the tibia freshened ; an inch 
of the fibula of the same leg was then taken from just below its head and fitted in between 
the ends of the tibia. No union followed, and in September 1891 the ends were again 
resected, and stout steel pins driven crosswise through the fragments, which, by reason of 
the shortening of the fibula, could be brought well into apposition. Round the ends of 
the pins silver wire was wrapped as in a harelip suture ; the wound was closed and the 

1 Studies from Old Case Books, 1891. 



Separation of the Epiphyses 803 

limbs fixed in plaster. In December 1891 the plaster was removed, and the bones were 
found united ; one of the pins was removed and the limb fixed in plaster of Paris. The 
union was firm when the limb was examined in August 1892, and the wound was quite 
sound, but the limb was still weak, and no restoration of the fibula had taken place. 
D'Arcy Power has collected a series of 72 cases ; in 45 of these, attempts to obtain union 
failed. ('Med. Chir. Trans.,' vol. lxxv.) 

Separation of Epiphyses. — Since the last edition of this book Mr. 
Poland's fine work on ' Traumatic Separation of the Epiphyses ' has appeared, 
and to it all who require a full account of these injuries must refer. A valuable 
series of papers on fractures of the upper extremity by Mr. Piatt has also 
been recently (1898-99) published in the ' Medical Chronicle.' Papers also by 
J. Hutchinson, jun., and his annotations in Helferich's work may be consulted. 
The discover}'- and development of radiography has of course enabled great 
additions to be made to our knowledge of these injuries. A pure epiphysial 
separation is met with commonly in certain bones, as in the case of the lower 
end of the radius (Plates X. arid XL), the upper end of the humerus, and the 
lower, end of the femur (J. Hutchinson, jun.). In many cases, however, 
and sometimes in those mentioned, the injury is a combination of fracture 
and diastasis (see Plates VI. and XII.) ; that is, the line of separation runs 
partly through cartilage and partly through bone. The periosteum in many 
of these cases remains untorn, and, as Mr. Hutchinson has shown, it is in 
many instances extensively stripped up from the diaphysis, and necrosis may 
follow. Hence the symptoms of epiphysial separation or diastasis vary con- 
siderably; thus there may be little or no displacement, crepitus may be absent, 
or very indistinct ; and undue mobility may be only recognisable on very 
careful manipulation. We have seen many cases in which there has been 
a history of previous injury, supposed to be a strain, in which the amount of 
thickening found at the time of examination makes it almost certain that a 
more or less complete separation of an epiphysis had occurred. This is espe- 
cially common about the lower end of the humerus, and our experience fully 
bears out Mr. Hutchinson's statement that these accidents are exceedingly 
common, and in any doubtful case of injury about the elbow they should 
always be suspected. Curiously, Hamilton (' Fractures and Dislocations ') 
says he has never met with a case. It is, however, possible that in some 
instances the violence may strip up muscles and the thick loose periosteum 
without any fracture or diastasis, and this injury of the periosteum may be 
the cause of the subsequent thickening. 

In well-marked cases there are deformity, undue mobility, loss of power, 
and sometimes indistinct or so-called 'false' or ' dummy' crepitus ; the outlines 
of the fragments are more rounded than in ordinary fracture, and the line of 
separation coincides with that of an epiphysis. It must be remembered that 
an epiphysial junction is not a flat, plane surface, but there is in many of the 
bones a cup-shaped hollow in the epiphysis which receives the rounded con- 
vex end of the shaft. It is often difficult to reduce and keep in place the 
fragments, and a certain amount of deformity is often persistent, though this 
diminishes by a gradual process of modelling as time goes on. Arrest of 
growth occurs in some cases, not in others ; probably this depends upon the 
accuracy with which the lesion has followed the epiphysial line, and the 
amount of destruction of the growing bone or of premature synostosis that 

3 F 2 



8 04 



Injuries , Shock, Hemorrhage, &c. 



results. Occasionally acute necrosis of a separated epiphysis occurs, or at 
least acute suppuration around it, and this is said to be disproportionately 
frequent in cases of separation of the epiphysis of the great trochanter and 
lower end of femur. (Hutchinson, junior.) These injuries are most common 
about the two ends of the humerus, the lower end of the radius, and the 
lower end of the femur. It is sometimes said that separation of the lower 
end of the femur is the most frequent accident, but in our experience it is 
not nearly so common as the diastasis of the humerus. We have once met 

with diastasis of the upper 
femoral epiphysis {vide 'Hip 
Disease in Childhood,' by one of 
the present writers) and ' which 
possibly (Plate XIV.) may have 
been a case of diastasis and frac- 
ture combined. Poland has col- 
lected a number of instances. 
Occasionally diastases are met 
with at the upper end of the 
tibia. 2 Tubby 3 has collected 
cases of separation of the 
clavicular epiphysis. The dia- 
gnosis depends upon the age of 
the patient, the fact that the 
projecting edge of the bone is 
sharp and unlike the natural 
inner end of the clavicle, as it 
would be in the case of a dislo- 
cation, and also in that a 
lamella of bone can be felt be- 
tween the sternal notch and the 
end of the shaft. It must be 
remembered that the epiphysis 
is only an extremely thin 
plate. We have lately met with 
an instance of this injury. 

According to Tubby, separa- 
tion of the coracoid epiphysis is 
of extreme rarity, and no case 
of separation of the acromial epiphysis appears to be authentic. 

Diastasis of the upper end of the humerus is not rarely met with. It 
results from injuries such as blows or falls upon the arm, which, in the 






Separation of the Upper Epiphysis of the 
Right Humerus. 



1 See also Stimson on Fractures, and Hutchinson, Arch, of Surgery, April 1892, and 
Tubby, Annals of Surgery, 1894, vol. xix. 

2 Separation of the upper epiphysis of the tibia has been caused by the bad practice of 
applying extension for hip disease below the knee instead of above it. 

3 Guy's Reports, 1889. 

Note. — For an account of separation of epiphyses due to congenital syphilis (syphilitic 
telostitis) vide chapters on 'Congenital Syphilis' and on 'Bone Diseases.' Similar 
multiple separations may be the result of so-called ' scurvy rickets.' 



Separation of the Epiphyses 



805 



adult, would probably cause either fracture of the shaft or dislocation of the 
shoulder. It appears to be not uncommonly the result of injury at birth. 
The appearance of the shoulder is characteristic, though much like that of 
fracture of the surgical neck of the bone. There is no depression below the 
acromion, but some flattening a little lower down, with a marked prominence 
on the anterior and inner aspect of the arm, a short distance below the cora- 
coid process. This prominence is the upper end of the shaft of the humerus 
displaced forwards and inwards ; the edges of the projecting bone are more 
rounded, and less sharp and 

Epiphyses of Head lc\ 



Tuberosities lie/ 



wU Shaft at 20^1/ H 



irregular than m the case of frac- 
tured surgical neck, and on re- 
duction, which is usually, though 
with difficulty, managed, 'dummy' 
crepitus instead of that of a true 
fracture is felt. It is difficult 
to keep the fragments in posi- 
tion, but, as the surfaces are 
broad, there is very rarely or 
never any actual overlapping. 
Since the upper epiphysis of the 
humerus includes the tuberosities, 
there is abundant blood supply 
to the upper fragment, and union 
usually takes place speedily. 
The treatment consists in apply- 
ing a long inside angular splint, 
well padded at the top and fitting 
high up t into the axilla. The 
fragments are brought into posi- 
tion, and a felt or gutta-percha 
shoulder-cap is then moulded on. 
Gentle active movement should 
be begun in ten days. The 
deformity is rarely entirely re- 
duced, but good union and a 
useful though possibly somewhat 
shortened limb results. If the 
displacement is considerable and 
cannot be reduced, operation is 
justifiable to correct it. The 

injury may be compound or complicated with rupture of the axillary artery. 
We have wired one case of compound separation with a good result. Instances 
of non-union have been met with, and shortening to the extent of five inches 
ten years after the injury. 

Separation of the lower epiphysis of the humerus is, we think, far the 
commonest lesion of the kind met with in children. It is very common to 
have children brought with an injury to the elbow of some days' duration, 
and a statement that the limb has been strained or the joint put out. On 
examination there is pain and restricted movement about the elbow joint, but 



Unites with 
Shaft at 



18 ^ 




r 



Fig. 208. — Plan of the Development of the Humerus. 
By Seven Centres. From Gray's ' Anatomy.' 



8o6 



Injuries, Shock, Haemorrhage^ &c. 



the olecranon, the head of the radius, and the internal condyle occupy their 
normal relations to one another. On grasping the lower end of the humerus 
between the finger and thumb, marked thickening as compared with the other 
side is felt usually just about the internal condyle. In such cases, if occurring 
in children under the age of six or seven, a mere loosening without displacement 
of the whole lower epiphysis may have occurred, or more probably the injury 
shown in Plate VI. without the displacement, and this is very likely the most 
common accident, though we have as yet no sufficient proof that it is so. 
Sometimes the whole lower epiphysis is separated and displaced backwards 





Fig. 209. — Separation of epiphysis of humerus, showing adduction 
of the forearm with loss of the ' carrying angle.' 



Fig. 210. — Arrest of growth 
of the radius from separa- 
tion of the lower epiphysis 
many }-ears before. 



(Plate VII.) ; more often the capitellum and outer condyle are detached 
(Plate IX.) and the inner side of the bone fractured (Plate VI.). Such cases, 
if seen at once, should be treated, after reduction of any obvious deformity, 
by gutta-percha or Gooch splint, on one side, and on the other an angular 
splint, reaching from the shoulder to the end of the fingers, or a posterior 
angular splint may be used. Treatment of these injuries of the lower end 
of the humerus by keeping the arm extended has been recommended as 
tending to diminish the displacement due to contraction of the triceps and 
the tendency to tilting of the fragments, but this method of treatment has 
not become the accepted one. H. O. Thomas, R. Jones, and others 



PLATE VI. 




Beatrice D., set. 1\ years. Separation of the whole lower 
epiphysis of the humerus, with inward displacement, 
and a vertical split in the shaft. The diaphysis projects 
outwards. Loss of 'carrying angle.' 



PLATE VII. 




Separation of the lower epiphysis of the humerus, 
with backward displacement. 



PLATE VIII. 




Separation of lower epiphysis of humerus, with T fracture. Subluxation 
of radius forwards. Injury four years ago. Good mobility. Boy 
aet. 11 years. 




Separation of the capitellar epiphysis in a girl ast. 7 years. There 
was mobility through about 70°, and good power of pronation 
and supination. A points to loose fragment. 



PLATE X. 




Separation of the lower epiphysis of the radius in a boy ast. 10 years. 



PLATE XI. 




Separation of radial epiphysis, with arrest of growth two 
years later. Boy aet. 12 years. A centre of ossification 
for the styloid process of the ulna exists. 



Separation of the Epiphyses 807 

recommend treatment by supination and extension, followed by acute flexion 
of the elbow, 1 and in cases where a radiogram shows a backward displace- 
ment which cannot be otherwise reduced the arm should certainly be put up 
in full flexion. At the end of a week the splints should be removed, gentle 
active movement encouraged, and the splints re-adjusted. A week later all 
splints should be left off and the arm worn in a sling, but taken out night 
and morning for gentle exercise. Violent passive movement to keep up 
flexibility is mischievous and delays the cure, since the irritation increases 
the amount of callus thrown out. If no passive or forcible movement is 
allowed, but just gentle voluntary exercise, absorption of all thickening 
gradually takes place, and, provided the displacement has been fairly 
corrected, almost perfect mobility will return in the course of a few months. 
The great point in treatment is to reduce the deformity and avoid forcible 
movement, but encourage gentle active movements after about the end of 
the first week. The ultimate prognosis is good as regards mobility, though 
uncertain as to arrest of growth. It occasionally happens that after separa- 




Fig. 211.— Separation of the lower epiphysis of the radius (photograph by Frank Ashe, M.B.). 

tion of the whole lower humeral epiphysis union takes place with the 
lower segment of the limb adducted, i.e. there is loss of the 'carrying 
angle,' and an unsightly and somewhat awkward limb {vide fig. 209 and 
Plate VI.). Loss of the 'carrying angle' or cubitus varus may arise in 
injuries of the elbow from displacement of one or other side of the lower end 
of the humerus or from abnormal growth after injury. It is very unsightly, 
but does not very seriously interfere with the use of the arm in most cases. 
In one case we twice osteotomised the humerus to remedy the deformity, 
which, however, recurred. Even if the limb is in the natural position after the 
accident, it may become deformed in the course of subsequent growth (Piatt). 
Separation of the epicondylar epiphysis is fairly common in patients from 
ten to sixteen years old, and the displacement is usually downwards. 

Separation of the lower epiphysis of the radius with fracture of the ulna 
is said to differ from Colles's fracture in that the palmar projection is more 
obvious, the hand is not held so obliquely, i.e. there is not so much radial 

1 Brit. Med. Jour. January 23, 1892, and November 3, 1894 ; also Helferich. 



8o8 



Injuries, Shock, Hcemorrhage^ 



<jrc. 



adduction, and the dorsal groove is horizontal instead of oblique. There is 
more resemblance to dislocation of the carpus backwards ; but this is an 
exceedingly rare injury, and in it the styloid processes do not maintain their 
normal relations to the carpus as they do in fracture, while the age of the 
patient and the sensation of crepitus, together with the ease of reduction, but 
ready renewal of deformity, will point to diastasis a (figs. 210 and 21 r, and 
Plate X). If the ulna is not fractured the resemblance to Colles's fracture is 
very close, and the treatment is the same. For cases illustrating these injuries 
in the upper extremities we must refer to Mr. Tubby's paper and Mr. Poland's 
work. Arrest of growth may follow (fig. 210, and Plate XI.). Very rarely 
the upper epiphysis of the radius is detached. We have once met with 
epiphysial separation at the symphysis pubis associated with rupture of 
the urethra. 

In separation of the lower epiphysis of the femur 
the lower fragment is usually displaced forwards, 
and the backward pressure of the diaphysis upon 
the vessels may cause gangrene, as in cases of 
Wheelhouse's and McGilFs of Leeds. 2 We have 
seen cases of compound separation of the lower 
epiphysis with similar displacement. The dis- 
placement should be rectified under chloroform, 
and the limb put upon a Macintyre's splint or an 
inclined plane. Reduction is more easily effected 
by flexion of the limb at knee and hip joints 
(Hutchinson). If necessary, the part should be 
exposed by operation and the deformity reduced. 
In many cases the onset of gangrene appears to 
have necessitated amputation. 3 The displacement 
is occasionally lateral. 

In separation of the upper epiphysis of the 
tibia, which is rare, the epiphysis is usually dis- 
placed forwards, though it may be laterally. We 
have seen a case of separation of the lower epi- 
physis of the tibia in a boy of about ten years who 
was under the care of our colleague Mr. Hardie. 
The case was complicated by the presence of a 
vertical fracture running upwards from the epiphysial line. The foot and 
lower fragment were displaced outwards, and the deformity could not be 
reduced until some weeks after the accident, when the ends of the bone 
were exposed by operation and with some difficulty replaced. We have 
also met with an instance of compound separation of the lower epiphysis of 
the fibula. The lower fragment became necrosed and was removed. 

The diagnosis of epiphysial separations need not be further described 
here : the locality, age of the patient, and the symptoms mentioned usually 
make the case clear, and any injury in the neighbourhood of a joint of doubt- 

1 Vide R. W. Smith on Fractures and Dislocations. 

2 Brit Med. Jour. May 24, 1884. 

5 Mayo Robson, Annals of Surgery ; 1893, vol. xviii. ; Tubby, Annals of Surgery, 
1894, vol. xix. 




Fig. 212. — Separation of lower 
epiphysis of left femur. The 
epiphysis is displaced for- 
wards, and the knee is 
flexed. 



PLATE XII. 




Separation of the lower epiphysis of the femur, with vertical fracture 
of the shaft. From a young man a^t. 18 years. 



Separation of the Epiphyses 809 

ful character should be treated as if a diastasis had occurred. After a few 
days the subsidence of the general swelling and the presence or absence of 
callus will clear up the doubt, even if a careful examination under chloro- 
form fails to reveal the exact nature of the injury. 

For further details, with records of cases, we must refer to Mr. Tubby's 
interesting papers, to Mr. J. Hutchinson's, jun., Lectures, published in 
the ' British Medical Journal,' 1893-94, and above all to Mr. Poland's book, 
which gives a complete account of the whole subject. 

The treatment of these cases is simply that of a fracture in the same 
position, though lighter appliances may of course be used in the case of 
children than of adults ; thus poroplastic felt, Gooch's splint, Hide's felt, 
gutta-percha or light wooden splints may be employed. Most careful padding- 
is necessary in all cases to protect the tender skin ; absorbent wool will be 
found the best material for this purpose. 

In separation of the lower epiphysis of the femur, as already stated, the 
limb should be put up in the flexed position, since the gastrocnemius, 
whether attached to the upper or lower fragment, tends to tilt the ends of 
the bone. 

Stimson mentions that Volkmann has three .times separated the lower 
epiphysis of the femur in manipulations required in cases of hip disease ; we 
once met with the same mishap in a case of acute suppurative arthritis in an 
infant. The ease with which diastasis occurred was probably due to inflam- 
matory or atrophic softening of the epiphysial line. The child recovered 
without arrest of growth. 

In all cases a guarded opinion should be given as to the future mobility 
of the adjacent joint, and movement should be begun early — in the case of 
the elbow not later than the end of the first week, the splints being re-applied 
afterwards, and movement employed daily after the first fortnight ; a week 
longer may be given for other joints. No forcible passive movement should 
be employed ; if the fragments have been replaced it is unnecessary and even 
harmful ; if they are still out of position, forcible movement is useless ; and 
if, after time has been given for absorption and modelling down of the parts, 
the limb is still seriously crippled, it is probably better either to resect the 
joint or to cut down upon and chisel away any projecting fragments of bone. 
Hence, if it is found that the thickening does not subside it is well to cease 
movement and allow the parts to settle down, and mobility will probably 
return without any special effort. Separated epiphyses unite with great 
rapidity, much more so than fractures. Even if there is considerable thick- 
ening and distortion for some weeks after the injury, and perhaps con- 
siderable loss of power and mobility, so much modelling of the parts takes 
place that ultimately the result is usually good. 

In cases of compound separation of an epiphysis it may be necessary to 
resect part of the shaft of the long bone in order to reduce the displacement. 
Even in such cases the amount of ultimate shortening may be very little, 
though it is quite uncertain how much it will be. 

Implication of the musculo-spiral nerve in the callus of a separated lower 
epiphysis of the humerus is not uncommon, and there may be paralysis of 
the nerve for a time ; usually, however, this disappears, and no hasty opera- 
tion for the release of the nerve is called for. 



8io Injuries, Shock, Hcemorrluzge, &c. 

The following table of the dates of ossification and union of the epiphyses 
of the principal long bones is inserted from Quain's ' Anatomy : ' 

Humerus. 

Nucleus of head appears in second year. 

„ capitellum appears in third year. 

„ interna] condyle appears in fifth year. 

„ trochlea appears in the eleventh to twelfth year. 

,, external condyle appears in thirteenth to fourteenth 

year. 
The lower epiphyses unite with shaft in sixteenth to eighteenth 

year. 
The upper epiphysis unites with shaft in twentieth year. 1 

Radius. 

Nucleus of lower extremity appears at end of second year. 

„ head appears in fifth year. 
Upper epiphysis and shaft join in seventeenth to eighteenth year. 
Lower epiphysis and shaft join in twentieth year. 

Femur. 

Nucleus of lower end appears at ninth month. 

„ head appears at end of first year. 
Head joins shaft at eighteenth or nineteenth year. 
Lower epiphysis joins shaft after twentieth year. 

Tibia. 

Upper epiphysis appears about time of birth. 

Lower epiphysis appears in second year. 

Lower epiphysis joins shaft in eighteenth to nineteenth year. 

Upper epiphysis joins shaft in twenty-first or twenty-second year. 

Simple complete fractures of the long bones may be met with at any 
age, and even occur sometimes in utero ; indeed, compound fractures may 
occur before birth. Intra-uterine fractures may be the result of falls or of 
blows upon the mother's abdomen, or of muscular contraction, and are some- 
times associated with intra-uterine rickets. Almost any number of fractures 
may thus occur ; 200 were found in one instance and 113 in another. Such 
fractures may be found united at birth ; they are not very rarely produced 
during labour by instruments or traction upon a limb. 

Fractures of the clavicle in quite young children are best treated by a 
flannel bandage to fix the arm to the side with the hand on the opposite 
shoulder, and a soft pad of absorbent wool in the axilla. The child's arm 
is, of course, kept inside its clothes, and not put through a sleeve ; as Mr. 
Owen suggests, a jersey may be usefully worn over the bandage to keep the 
limb quiet. In this, as in all fractures, it is an excellent plan to keep the 
skin well powdered with boric acid or sanitary rose powder, so as to prevent 
irritation of the skin. 

1 Stimson says sometimes as late as the twenty-fifth year. 



PLATE XIII. 




Fracture above epiphysial line of lower end of humerus. 
Loss of 'carrying angle.' Boy aet. 6 years. Injury 
four months ago. 



PLATE XIV. 




Fracture of neck of femur, possibly diastasis 
Boy set. 11 years 



Fractures 8 1 1 

Fractures of the arm are treated in the ordinary way ; the splints should 
always be carried well up to the ends of the fingers to prevent disturbance 
of the fragments by the restless movements of children. We are well aware 
that this is not usually recommended, but we believe it to be the proper, as 
it certainly is the anatomically correct plan. Fractures of the pelvis are 
treated by bandaging the legs together firmly with a broad flannel bandage, 
which is carried upwards to above the crests of the ilia, the child being, of 
course, kept in bed. 

In fractures of the femur in babies under a year old a piece of gutta- 
percha or Gooch's splint, lined with wool, should be applied to the thigh, 
and the legs bandaged together with a flannel bandage ; this is, we think, 
the simplest, cleanest, and, on the whole, most effectual plan, though a good 
result may be obtained by almost any method. In older children, up to the 
third or fourth year, we prefer the vertical suspension plan, as more cleanly 
and efficient, and less troublesome after it is once applied than other 
methods ; simple extension by a weight, with Gooch's splint, or an outside 
long splint, is, however, satisfactory, and a Croft's, a Bavarian, or a 
Thomas's hip splint should be applied at the end of a fortnight. Thomas's 
knee splint may also be used very successfully in fractures of the lower half 
of the femur. 

After fracture of the thigh in simple cases there should not be at most 
more than half an inch shortening in young children, and this will very 
likely disappear after a time. 

Fracture of the neck of the femur occasionally occurs in children. 

Case. — W. L. S. , aet. 14. Fell from a door in Ma)- 1896. He was laid up for a fort- 
night. When seen, six months later, there was one inch shortening of the right leg, no 
abduction or adduction. The trochanter was raised to the level of the anterior superior 
spine. There was some stiffness, and no pain. The radiogram Plate XIV. was taken six- 
months after the accident, when he was an out-patient at the Children's Hospital. 

Fractures of the leg should be treated by a back splint with a foot-piece 
and two side splints for the first ten days or a fortnight, or more, according 
to age, and then one of the forms of stiff apparatus applied. 

In all cases the most careful watch must be kept for tight bandages ; no 
bandage should ever be applied beneath a splint, nor should a limb be ever 
bandaged in extension and then put up in flexion. Pressure sores and 
gangrene are real dangers in children. 

As is well known, any cause, such as hip disease, infantile paralysis, old 
anchylosis with atrophied bone, rickets, and so on, may produce weakening 
of the limb and may predispose to fractures from slight violence. When 
extensive necrosis has occurred, a slight injury may produce a fracture in 
childhood ; this usually unites well, but in some cases union is tedious, and 
in others does not occur : in such cases resection and wiring is a successful 
operation in our experience, but if the fracture remains long ununited the 
wasting of the fragments is apt to be extreme, and in one instance the upper 
fragment of the humerus was so small that it was found impossible to steady 
it sufficiently to obtain union. Macewen has dealt with such a case most 
successfully by transplantation of bone {vide ' Ununited Fractures'). This 
bony atrophy should always be borne in mind when dealing with such limbs. 

Mal-united fractures, if recent, and especially if greenstick, should be 



8i2 Injuries ; Shock, Hemorrhage , &c. 

refractured at once ; if seen after three or four weeks, and when union has 
occurred, gradual reduction with splints often produces good results. Failing 
this, refracture or osteotomy may be called for. 

Primary Amputations in children are very rarely required, and conser- 
vatism should be carried to extreme limits ; when amputation is necessary, 
if the immediate shock is got over, recovery is usually rapid. We have had 
once to perform a primary amputation at the hip in a child five years old for 
a tramcar injury, and, though there was much 'prostration with excitement'' 
for the first two days, he ultimately did well. 

Primary Resections of joints are occasionally required, and in cases of 
injury to the elbow are spoken very highly of by Mr. Holmes. The need for 
them is, however, now exceedingly rare. 

Dislocations. — Almost the only dislocation at all common in children is 
that of the elbow— both bones being displaced backwards. This is usually 
said, and we believe correctly, to be more frequently met with in childhood 
than in adult life. Dislocation of the elbow is, however, often complicated 
with separation of epiphyses or fractures, and the displacement is often not 
directly backwards, but backwards and laterally, either inwards or outwards. 
Passive movement should be begun at the end of a week at latest. 

Dr. W. T. Clegg ; of Liverpool, has sent us a case of subspinous dis- 
location of the shoulder, probably caused at birth ; this is the only case we 
have seen. 

Subluxation of the head of the radius is often met with in children as a 
result of lifting the child by one arm, swinging it round, or dragging it along. 
The head of the radius slips partially out of the orbicular ligament, and the 
arm is found to be fixed, powerless, somewhat flexed and pronated ; there is 
usually pain both at the elbow and wrist, so that sometimes the injury has 
been thought to be situated at the wrist joint. Reduction is effected by 
steadying the upper arm, and, with the thumb over the head of the radius, 
supinating sharply, and then flexing the forearm upon the arm ; sometimes 
a distinct click is felt or heard, and the power of using the arm at once 
returns. 1 

We have only rarely met with a traumatic dislocation (dorsal) of the hip 
in children. Reduction is easy by manipulation. Dislocation of the patella 
is occasionally met with ; there appears to be usually some congenital weak- 
ness of the part as a predisposing cause, as in the case appended. 

Case. — Dislocation of Patella. — Mary Alice N., aged 7 years 6 months; admitted 
February 7, 1883. History : Not strong, did not' walk till three years old ; seven months 
ago fell while dancing and dislocated the left patella outwards ; since then has been con- 
stantly falling on account of the displacement recurring, especially if she runs ; the injury 
caused her no great trouble for a week, when the displacement was noticed ; was treated 
as an out-patient for some time, with pads and various appliances to keep the patella in 
place, but without success. On admission, the left patella during flexion lies quite on the 
outer side of the external condyle, coming back to its normal position on extension ; both 
femora have their external condyles very prominent ; no pain on manipulation or move- 
ment ; the patella was unnaturally small and could easily be moved about from side to 
side ; when walking it sometimes maintained its proper position, and then without warn- 

1 This injury has been specially described by Mr. Jonathan Hutchinson, jun. , and by 
Drs. McNab and Lindeman, Brit. Med. Jour. December 5, 1885, 



Dislocations 



813 



ing would slip quite over the outer condyle and make the leg yield. February 17, a 
lateral incision was made over the inner side of the joint down to the capsule, the patella 
pushed strongly inwards, and two catgut sutures, passed through the inner edge of the 
patella, were tied firmly down to the tissues on the inner side of the joint ; operation 
antiseptic ; back splint. 19th, has had a little pain ; did quite well ; antiseptics left off 
on March 3, and she was sent out in plaster of Paris splint on the 5th. Seen January 
1884, the patella keeps its place and the knee does not trouble her. In this case the 
patella was apparently congenitally small and ill developed, and this probably accounts 
for the condition. 

Subluxation of the knee has been recently described by Mr. H. B. 
Robinson as occurring in children about twelve months old, and apparently 
the result of relaxed muscles and ligaments. The tibia becomes displaced 




Fig. 213. — Dislocation of the Patella, a points to the displaced bone. 

outwards, and rotated out on attempts being made to walk. Attention to 
the general health and friction are the only modes of treatment required, 
and the tendency to displacement disappears as the child grows stronger. 1 

Congenital Dislocations are considered under the head of Malforma- 
tions (p. 750). 

Injuries of the Soft Parts in children require no special notice ; if the 
immediate shock is got over, such wounds usually heal with great rapidity 
even if very severe, and nothing short of actual gangrene (Holmes) should 
be considered justification for amputation. Warmth, opium in small doses, 
and free stimulation are especially required for all severe injuries in children. 

Burns and Scalds are exceedingly fatal, chiefly from shock, lung com- 
plications, and cerebral effusion. If the first few days can be tided over, 
recovery is usually satisfactory, and much more rapid than in adults. Care- 

1 Brit. Med. Jour. July 27, 1895. 



8 14 Injuries^ Shock, HcemorrJiage, &c. 

ful watch for cicatricial contraction must be kept up, and provision made 
against it by suitable extension apparatus and manipulation, as well as by 
grafting. Plastic operations may be required at a later date. 

Shock. — -The question of how children bear the shock of severe injuries 
or operations, and the effects of loss of blood and of pain, is one of much 
importance to the surgeon, and may be shortly considered here. First, then, 
as regard operations in infants and quite young children one great depressing 
element is removed. They do not anticipate and are not cast down by the 
thought of the effect upon their future usefulness of any mutilation. In some- 
what older children anticipation of pain is of course keen, but it seldom de- 
presses in the same way that it does in adults. Again, the temperament of 
children is usually mobile, and, even if mental depression occurs, it is not 
long lasting. So with shock from a severe injury or operation, the symptoms 
are often severe, even more so than in adults, for a short time ; but, if by 
means of stimulants the first few hours can be got over, children very 
quickly rally. It is common to have a great amount of shock in a child 
after such an operation as an amputation or excision of one of the larger 
joints, and yet the next day the child is often as bright as if nothing had 
happened. On the other hand, occasionally we see ' prostration with excite- 
ment ' in a severe form in children, and we have known a mental condition 
practically identical with acute mania coming on after amputation at the 
shoulder joint, and lasting for some weeks, followed by complete recovery. 

Xioss of blood is always very ill borne by children, and the more so the 
younger the child. Still, recovery is rapid if the child survives. Even the 
small quantity lost in a harelip operation sometimes seriously endangers 
the life of an infant a few weeks old, and in all cases great care should be 
taken to avoid haemorrhage as much as possible. The only instance of 
death from amputation at the hip joint that we have had in a child was in 
one where, from removal of a large part of the pelvis, free oozing took place. 

Next to loss of blood we should put cold as having the most depressing 
effect upon children, and this should always be carefully guarded against by 
exposing as little as possible of the body beyond that part actually being- 
operated upon. 

Pain, if really severe, very seriously depresses a child, far more so 
than it does an adult, and many of the cases of severe burn die speedily 
from the combined effects of pain and fright. Hence, no child should be 
allowed to lie in pain after an operation, and opium should be given freely 
for a few hours till the first soreness has passed off, bearing in mind, 
of course, that opium has a disproportionately strong effect upon children, 
and that some children bear much smaller doses than others. The general 
rules, then, to be followed as to the management of surgical cases in 
childhood are: (i) Do not let a child know that he is going to be 
operated upon, until the time actually comes for the operation. (2) Avoid 
with the utmost care unnecessary loss of blood. (3) Keep the child warmly 
wrapped up. (4) Never let a child suffer pain if it can be avoided ; thus, an 
anaesthetic should be given for any painful dressing or manipulation, and 
opium as soon as recovery from the anaesthetic has taken place. 

As Mr. Holmes has well pointed out, in children ' irritability is chiefly 
directed against sudden and acute pain ; but confinement to bed and 



Septic Diseases 815 

protracted disease, which wear out the patience and exhaust the hopes of 
older persons, soon become customary in childhood, and then produce little 
impression/ As Mr. Holmes shows, freedom from mental depression and 
healthy, unimpaired excretory organs probably account for this difference. 

Children are, of course, liable to the same septic diseases as adults, and 
pyemia is, though happily rare in both, quite as common in childhood as in 
older patients. Diphtheria, and especially scarlet fever {vide Chap. XIV.), 
are very apt to attack surgical cases among children, i.e. those in whom there 
is a wound or a local inflammatory focus ; while erysipelas, though not very 
rare and occasionally fatal, is mostly of a mild type in children, and in our 
experience the so-called ' erysipelas vagans ' is the variety most commonly 
met with. See, however, Vaccination Erysipelas, p. 310. 

' Surgical scarlet fever,' so-called, is nothing more than ordinary scarlet 
fever. It is now well known that children who have open wounds, who have 
been recently operated upon, or who have local inflammatory foci, such as 
abscesses, are specially susceptible to scarlet fever. For further details and 
references we must refer to papers by Dr. Goodhart and Messrs. Howse 
and Paley, in the ' Guy's Hosp. Repts.' for 1879, and to an account of an out- 
break in our own surgical ward, by R. W. Murray, in the ' Brit. Med. Jour.' 
June 18, 1887. 

No special remarks are required upon the subject of dressing wounds in 
children ; the same rules should be followed as in adults. We use anti- 
septics — chiefly boric and mercurial lotions, with iodoform and sublimate 
wood-wool wadding — and are fully satisfied of the value of these agents. 
Mercurial poisoning in children we have not certainly met with, and only 
iodoform poisoning in a few instances, and those of a very mild type. We 
have twice had a fatal result follow within twenty-four hours of emptying 
and washing out a large abscess, but we have been unable to connect the 
death definitely with the use of any particular antiseptic agent, though we 
have suspected perchloride of mercury of being dangerous in such cases. 

In certain cases — for instance, in circumcision — it is well to avoid the 
fright of a second manipulation by the use of catgut sutures in closing the 
wound, and it may be remarked that primary union of wounds in children is 
much more easily obtained than in adults, providing the child is healthy and 
not too young ; in the very young the tissues are too soft to bear any strain, 
and in childhood the very smallest disturbance of health is sometimes 
enough to prevent union of a wound ; hence all plastic operations should be 
performed only after careful inquiry into the child's general condition. The 
same slight causes will often produce a temperature chart that would be very 
alarming if it were not known how little is required to raise a child's tempe- 
rature. As to the dieting of children after operations, it will be found that 
children can without harm much more speedily return to their ordinary 
diet than can adults, and it is common for a child to resume its usual food 
the day after an operation. 

We have two or three times met with cases of persistent vomiting after 
operation resisting all treatment and even proving fatal by exhaustion. In 
one instance, after operation for cleft palate, the vomiting was followed by 
purpura, gangrene of the extremities, endocarditis, and death from acute 
septicaemia. 



8 1 6 A ncesthetics for Children 



CHAPTER XL 

ANAESTHETICS FOR CHILDREN 

By Alexander Wilson, F.R.C.S. 

In the production of anaesthesia in children, as compared with adults, 
there are two questions to be chiefly considered . their physical conformation 
— that is, their capacity for the inhalation and absorption of the anaesthetic 
vapour — and its reaction on their more unstable nervous and usually healthy 
vascular systems. 

General anaesthesia takes place when the blood of the subject contains a 
certain definite quantity of the anaesthetic agent employed, which is intro- 
duced through the lungs, by the inhalation of air impregnated with the 
anaesthetic. It follows that the strength of the anaesthetic vapour being the 
same, the rapidity with which the blood absorbs and distributes the 
necessary amount of the drug will depend upon the depth and frequency 
of the respirations, i.e. upon the vital capacity, and also upon the vigour of 
the circulation in proportion to the size of the animal, small animals, 
which breathe deeply or quickly in proportion to their size, becoming affected 
sooner than larger animals, which breathe slowly. 1 

Compared with adults, children present well-marked differences. Their 
chests are usually well developed, highly expansile, and the lungs more 
likely to be healthy and in better working order. They consequently have, 
in proportion to their size, a larger vital capacity than most adults, that 
is, a proportionately larger lung area for the inhalation and absorption 
of any anaesthetic vapour. Their healthy vascular system and active 
circulation enable the blood to quickly absorb and transfer the inhaled drug to 
the tissues, and their smaller size causes the system to become more quickly 
affected. In practice the influence of these factors is often increased by the way 
in which young subjects usually take anaesthetics, e.g. crying, and alternately 
holding the breath and taking deep inspirations. The foregoing considera- 
tions account for the rapidity with which children go ' under ' with 
anaesthetics, and one has seen a crying struggling child reduced to an almost 
lifeless condition by one deep inspiration of a concentrated vapour of 
chloroform. Owing to this capacity for the inhalation and absorption 
of anaethetics and the small size, less anaesthetic is required ; so in giving 
them anaesthetics caution is necessary, and an over-dose may easily be 
inhaled. 

1 Snow, On Ancesthetics, p. 70. 



■H. 



Difference between Children and Adults 817 

As regards the effect of the anaesthetic, children possess no special 
resisting power against the lethal action of either chloroform, ether, or 
any other anaesthetic. In proportion to the number of administrations, 
probably fully as many accidents have happened in the case of children 
as in adults. They are better subjects than adults merely in so far as 
they are more free from those degenerative changes which in older subjects 
complicate the administration. They also have an advantage in not 
being .habituated to the excessive use of alcohol, &c. Further, as, from 
the elasticity of their chest wall and their smaller size, treatment in 
accidents can be better and more successfully applied, there are in con- 
sequence fewer fatal cases. 

Apart from the rapidity with which the anaesthetic can take effect, such 
differences in its action as exist are to be traced largely to the activity of the 
reflexes and the lack of inhibition over certain functions which obtains in 
young subjects. Thus the occurrence of defecation and micturition is more 
common in children, probably. because these acts are with them normally 
under less control. The crying reflex is abnormally active in early life, and 
so during an operation a child will often cry out at a stage of the narcosis 
where an adult would either exhibit no sign of feeling or merely move 
slightly. Perception of pain does not necessarily accompany the crying. It 
is a common occurrence for a child to emerge shrieking from nitrous oxide 
anaesthesia, and yet for it to have no painful impression nor any idea why 
it is crying. This readiness with which children cry out is partly responsible 
for the belief that they ' come out ' of chloroform anaesthesia more quickly 
than adults. 

In adults we see spasm of the glottis producing loud crowing inspiration 
as a reflex from forcible dilatation of the sphincter ani. In children this is more 
readily originated, even when the patient is apparently well ' under,' and 
accompanies any painful operative procedure. It is especially well marked 
on division of the prepuce or in operations involving the anus during 
moderately deep narcosis. It represents an abortive expulsive effort, and 
denotes an imperfect degree of anaesthesia, and is relieved but not removed 
by extending the head and pushing forwards the jaw, and giving more of the 
anaesthetic. If the painful part of the operation is of momentary duration, it 
is not necessary or advisable to push the anaesthetic to the extent of 
abolishing this reflex. 

Other points of difference between children and adults dependent upon 
the nervous system are the various reflexes by which the degree of narcosis 
is estimated. The corneal or lid reflex, uncertain as it is in adults as a 
guide to the condition of anaesthesia, is still more unreliable in young- 
subjects. In applying this test do not hold up the lid in such a way as to 
prevent it closing, and always test both eyes. The reflex may be present 
throughout an operation though no other signs of sensation are exhibited, 
it may be present in one eye and absent in the other, and it may be absent 
in both eyes and yet the patient exhibit signs of sensibility. In the latter 
condition the pupils are contracted and the eyes have a fixed look, and there 
are generally other indications of decrease in the anaesthesia. It has been 
suggested that this absence of corneal reflex may be due to the local 
anaesthetic effect of the chloroform vapour. The inferences deduced from 

3 G 



8 1 8 A ncestJictics for Children 

the lid reflex must be checked by observation of other conditions, such as 
the quantity of anaesthetic the patient has taken, the respirations, facial 
expression, the swallowing reflex, movements of the fingers, and nature of the 
operation. 

Emergence from the narcosis is indicated by alteration in rhythm of the 
respirations, slight holding of the breath with tendency to spasm of the 
glottis, or acceleration of the respirations. 

Alteration in the facial expression, pursing of the lips, or wrinkling of the 
forehead, and extensive movements of the fingers are signs of recovery. 
Swallowing is a late reflex to disappear and an early one to re-appear, and 
is a valuable index to the stage of anaesthesia. 

Symptoms of vomiting also denote a return to consciousness. An 
intelligent observation of all these points will usually enable the adminis- 
trator to avoid making mistakes. 

The state of the pupils alone is not much guide to the degree of narcosis. 
They are dilated at an early stage, generally moderately contracted later, 
dilate on the onset of nausea and vomiting, and dilate widely in collapse. 
The significance of these signs, like others, must be interpreted in conjunc- 
tion with other symptoms. 

Children are very susceptible to shock, and no suddenly painful pro- 
cedure (e.g. wrenching a joint) should be undertaken when they are in a 
semi-anaesthetised state. Though the occurrence of reflex paralysis of the 
heart has been denied by certain recent observers (Hyderabad Chloroform 
Commission), we have seen one case (a young girl) in which death was 
clearly due to shock produced by flexing a limb when the patient was not 
completely under the influence of the anaesthetic. 

The Choice of an Anaesthetic. — In this connection it is not necessary 
to consider any anaesthetic agents other than ether, chloroform, and nitrous 
oxide, or their various combinations. As regards relative safety, children 
are in the same position towards these drugs as are adults. In lethal power 
chloroform comes first, ether next, and nitrous oxide last ; the latter, it must 
be remembered, has not been used to any extent for the production of 
prolonged anaesthesia. The attempts at present being made to employ 
it for long operations may possibly prove that there is a limit to its safe 
use. In selecting an anaesthetic for a young subject, too much stress must 
not be laid upon the mere question of age ; extreme youth does not neces- 
sarily contra-indicate the exhibition of ether, nor make imperative the use of 
chloroform ; if necessary, ether can as readily be given to an infant as to 
an adult. 

Local Anaesthesia for exploratory punctures may be produced by 
holding a piece of ice dipped in salt against the surface until it is frozen, by- 
ether spray, or by ethyl chloride. Cocaine, from the method of applying 
it, from its irregular action, and the unpleasant symptoms it sometimes 
causes, cannot be much used for children. 

Nitrous Oxide is well borne by children, they pass rapidly under its 
influence, but the period of anaesthesia is short, and muscular movements, 
spasm, and opisthotonos are usually much greater than in adults. It may 
always be used in dental and short surgical operations. The period of 
anaesthesia can be prolonged and the muscular disturbance diminished by 



Chloroform. Etlicr 819 

combining it with oxygen or a little ether. This latter is, however, liable to 
cause sickness, which may also occur after prolonged anaesthesia from the 
gas alone. 

Chloroform in the case of children possesses many advantages, but it is 
not altogether the safe and desirable anaesthetic it is often represented to 
be. Children, as already stated, possess no special powers of resistance 
against the lethal action of chloroform, and a fair number of deaths, and 
many more alarming but non-fatal accidents, have occurred from its use in 
young subjects. 

The youth of the patient is a source of safety only because it implies a 
freedom from degenerative changes in the nervous, respiratory, and vascu- 
lar systems. 

The advantages of chloroform consist in the simplicity of the apparatus 
required, the small quantity needed, its sweet pleasant flavour, and the fact 
that it produces no bronchial irritation. As disadvantages may be mentioned 
the facility with which an overdose may be inhaled ; the depression it pro- 
duces, indicated by pallor, feeble pulse, dilated pupils. The nausea and 
faintness after the administration are often considerable, and have led some 
surgeons to prefer ether as the routine anaesthetic for children. With 
chloroform there is often difficulty in producing narcosis, and in estimating 
and graduating the degree of anaesthesia. If during the operation there is a 
return of sensation, it is not so easy to re-induce anaesthesia with speed and 
safety. This arises from the circumstance that when once a certain degree 
of unconsciousness is produced the breathing becomes so shallow that 
barely enough chloroform is inhaled to advance the narcosis, or if the 
patient is ' under ' to keep it up. 

Ether, compared with chloroform, is less depressing ; the pulse continues 
strong throughout, the respirations active ; the face keeps a good colour ; 
the tendency to syncope is diminished, and the after-sickness is of shorter 
duration, often ceasing when once the stomach is emptied of mucus. It is 
quicker in its action consistent with safety, so that the distressing struggles 
of a child can be speedily ended without danger in a way that could not be 
done with chloroform. It is much easier to calculate and maintain a definite 
degree of narcosis, and if signs of returning sensation or of vomiting appear 
a deeper anaesthesia can be speedily and safely re-induced, probably because 
the drug causes active respirations and is therefore more freely inhaled. 
The risk of suddenly giving an over-dose is almost nil. Ether, however, has 
disadvantages ; it requires some apparatus for its proper administration, it 
occasionally causes a considerable secretion of mucus, and when given 
alone it is unpleasant. The last of these objections can be overcome by 
giving it in combination with nitrous oxide, or by first giving a little chloro- 
form. The secretion of mucus in children is no greater than it is in adults, 
and when the inhalation is properly managed only in the minority of cases 
is it enough to give any trouble. When excessive it may readily block up 
the small trachea and bronchial tubes, and give rise to inconvenience, 
especially if the patient is kept deeply narcotised. In these cases changing 
the anaesthetic to chloroform does not immediately improve matters, as the 
change does not remove the mucus ; it is better to allow the patient to 
recover consciousness enough to clear the lungs by. coughing. Ether is 

3 G2 



820 Anczsthetics for Children 

contra-indicated in lung- disease, and is supposed to be dangerous in kidney 
diseases. 

The A.C.E. Mixture is a weaker anaesthetic and not as depressing as 
chloroform, and so safer ; but it is not as safe as ether. 

These anaesthetics are also used in combination, the object being to 
blunt the sensibility to the pungency of ether vapour. The principle of all 
these combinations is first to give the more agreeable anaesthetic until 
sensation is dulled and then replace it with pure ether before the stage of 
excitement. The most useful is nitrous oxide and ether ; but as it entails 
the employment of apparatus, its use is confined to older children. The 
initial exhibition of chloroform or A.C.E. followed by ether is very valuable. 
Certain anaesthetists have reduced the arrangement to a definite system. As 
an example of these methods, Mr. Rowell recommends that A.C.E. should 
be first given in drop doses on a piece of lint or Skinner's inhaler, to be 
followed by a stronger vapour of A.C.E. from a Rendel's mask, to which 
when unconsciousness supervenes should be added a drachm of ether, to be 
followed when narcosis is further advanced by the exhibition of pure ether 
from a Rendel's mask, with which the anaesthesia is afterwards kept up 
throughout the operation. 

Preparation. — As anaesthetics are best taken when the stomach is 
empty, their administration should not be undertaken within three or four 
hours of a meal. When possible, it is best to arrange for operation at the time 
when a meal is due — e.g. about the hours nine, one, four, or six. As children 
bear badly the deprivation of food, any longer interval, besides being 
unnecessary, is injurious, making the patient feel faint. A feeble child, or 
one kept long without food, should be given some liquid nourishment some 
little time before operation. 

In every case it is well to have at hand chloroform, ether, and A.C.E. 
mixture ; the administrator should also have a plentiful supply of lint, 
tongue forceps, a hypodermic syringe, nitrite of amyl capsules, sponges, an 
electric battery, and a mouth-gag with a sponge-holder. These latter are 
occasionally required in cases of vomiting. 

Before beginning the administration, examine the mouth for any loose 
temporary teeth which might become detached, especially if a gag is to be 
used, and also in better-class children for any dental regulating plates ; 
avoid, if possible, alarming the patient, for with a struggling, crying child 
the danger of giving an overdose is increased. By a little tact most 
children can be anaesthetised without any crying, even when inhalers are 
used. If the child is'nervous, let it sit on its mother's or nurse's knee. If 
the little patient is not undressed, do not have the clothes removed until it 
is anaesthetised ; the undressing can then be managed without alarming 
it. Let the child see the inhaler or lint and smell it before any anaesthetic 
is put on, and begin with a very weak vapour. During the administration, 
when the smell is objected to, incite the patient to ' blow it away.' It is not 
absolutely necessary that the child should be lying down in the early stages ; 
if quiet can be gained by letting it sit up, permit this. These small details 
are of importance, as there is no doubt that to a highly sensitive child the 
struggling and shock of being 'choked off' by an anaesthetic may have 
injurious after-effects. Should the child cry, go on steadily with the 



Ether. Chloroform 821 

administration, but do not give an extra quantity or ' push ; the anaesthetic 
to get it ' under' the quicker. As it is breathing" more deeply than normal, 
rather exhibit less of the anaesthetic, and so avoid all chance of the sudden 
inhalation of an excessive dose. 

Ether when given alone is best administered by a Clovers inhaler. It 
should be given slowly, with a free admixture of air. In nervous subjects 
the face piece may be applied first, and when the patient is accustomed to 
it, the ether box and bag may be added and free respiration into the bag 
established before ether is admitted. Should the patient become highly 
excited and rough, it is allowable to turn on a stronger vapour and hasten 
the anaesthesia. 

When possible it is always desirable and more humane to begin the 
anaesthesia with some less pungent anaesthetic. Of these nitrous oxide is 
the best, and the most convenient apparatus is Hewitt's modification of 
Clover's inhaler. Very little gas is required, and the ether should be turned 
on before the nitrous oxide has produced any muscular disturbance. The 
strength of the ether vapour can be estimated by its effect on the pharynx ; 
if it produces swallowing, or catching respiration, it is too strong, and a 
weaker vapour should be presented to the patient, as it is important not to 
irritate the pharynx and lungs. It is better that the patient should breathe 
freely a weak vapour of ether than have a strong irritating vapour forced on 
him. The onset of anaesthesia is indicated by the signs already mentioned ; 
of these an important one is the absence of swallowing or irritation when 
the index of the inhaler is turned to ' three' or 'full.' When once 'under' 
a very little ether is needed to maintain narcosis. Should there be indica- 
tions of excessive secretion of mucus, chloroform or A.C.E. may be cautiously 
substituted for the ether ; care must, however, be taken that in the deeper 
respirations and quicker pulse induced by the ether, an overdose is not 
inhaled. Failing nitrous oxide, a little chloroform or A.C.E. may be first 
given. 

Chloroform is most conveniently given on lint. First put a little vaseline 
on the face to prevent blistering ; place the fold of lint over the nose and 
mouth, and then gradually drop the chloroform on it. When the patient 
objects, coax him to ' blow it away.' 

It is a good plan, standing on the patient's right, to hold the lint on the 
nose with the left thumb and forefinger, pressing on the nasal bones, while 
the third and fourth fingers spread over the forehead, feel the pulse of the 
anterior temporal artery, and steady the head ; the right hand is then free 
to drop on the chloroform and control any movements. In dropping the 
chloroform hold the bottle near the lint ; if it is dropped from a height, it is 
extremely easy for a little to get into the eye. 

Hold the child as little as possible. If it seizes the lint, quickly replace 
it with a fresh piece rather than waste time struggling for the first ; never 
try with chloroform to ' send it over quickly.' Each inspiration means one 
dose of the drug, which takes effect some seconds after its inhalation ; 
therefore remove the lint at the first sign of anaesthesia, or the patient will 
inhale several unnecessary doses. The quickness with which children 
become unconscious has been referred to. It occasionally happens, especially 
when there is some obstruction to respiration, that after a certain degree of 



822 A?icusthetics for Children 

unconsciousness is reached the patient breathes so quietly that it is difficult 
to induce complete narcosis, and nausea with feeble circulation is produced. 
This may be overcome by stimulating the respirations by rubbing the chest, 
pinching the jaw, or, better still, by giving a little ether. 

As the pain during an operation varies with the tissues cut, it is not 
necessary to keep the patient deeply narcotised throughout the operation, 
and though the patient may wince with the skin incision, the remaining steps 
of the operation may cause no signs of sensation. 

Should there be coughing, in the deep inspiration following the cough 
do not let the patient inhale too much chloroform vapour, and be careful 
not to mistake the general jerking of the limbs caused by the coughing for 
voluntary movements requiring more chloroform. It is occasionally difficult 
to abolish reflex movements entirely during an operation on the skin, and 
the anaesthetist must therefore not respond too readily to the ' More chloro- 
form, please,' of the operator. 

Spasm of the glottis with crowing inspiration is very common, especially 
if the patient is not quite 'under' or is beginning to have nausea; it is 
generally a sign of imperfect anaesthesia, and when accompanied by such 
signs as rigidity of the jaw muscles, contracted or slightly dilated pupils, 
and a good pulse, is an indication for more of the anaesthetic ; the spasm is 
partly relieved by pushing forwards the jaw with the neck hyper-extended. 
As previously remarked, pulling out the tongue with forceps does not remove 
the spasm. Such treatment is rarely required, and should be avoided as 
much as possible, as being liable to cause unnecessary after-pain in the shape 
of a sore tongue. If it is considered advisable to keep the tongue drawn 
out, it should be gently held out with a pair of tongue forceps, or, better 
still, by the fingers and a piece of lint. The lower jaw can be conveniently 
held forwards by using the closed forceps as a lever, the upper teeth acting 
as the fulcrum, care being taken not to loosen them. 

During the administration the same rules should be observed with 
children as with adults. 

When once the child is ' under ' it is very important to avoid moving it 
suddenly or roughly ; such treatment tends to cause syncope. This caution 
is especially necessary if there has been any loss of blood or if there is faint- 
ness. Under these circumstances never allow a patient to be raised up into 
a sitting or semi-sitting position for the application of dressings. . This can 
easily be avoided by drawing the patient to the end of the table and 
supporting the body so that the head and shoulders project beyond the 
table ; full access can thus be gained to any part without in the least raising 
the trunk. We have seen a serious attack of faintness brought on by the 
sudden raising of the head and shoulders of a child at the end of an opera- 
tion in which a considerable amount of blood had been lost. 

In connection with this it is important to remember that feeble respira- 
tions are not always associated with shock. One of the most' serious 
symptoms of cardiac and general failure is deep gasping respiration 
accompanied with a quick running pulse. If, in a patient undergoing a 
severe operation, ordinary quiet respiration suddenly gives place to deep 
inspirations, especially if they are of a gasping character, associated with a 
quick pulse and dilated pupil, it is a sign of the onset of serious if not fatal 



Anesthetics in Special Operations 823 

syncope. This is not as common in children as in adults, but it occurs in 
them under similar conditions. It is due to sudden anaemia of the respi- 
ratory centre, whether caused by actual loss of blood or cardiac failure. 

Vomiting-, if the stomach is empty, can be overcome by giving more ' 
chloroform ; otherwise it is better to suspend the administration until the 
stomach has been emptied, and then to resume it ; turn the patient well 
on one side during vomiting, and keep the mouth and pharynx clear. A 
patient with a loaded stomach will breathe badly, have stertor, and present a 
more or less cyanotic appearance. Frequently the vomiting will be preceded 
for some time by a condition in which the patient presents a feeble pulse, 
irregular, stertorous, or spasmodic respirations, and more or less cyanosis, 
which is improved when once actual vomiting begins. 

Ar aesthetics in Special Operations. — There are practically no 
conditions under which an anaesthetic is contra-indicated ; if an operation 
can be performed, an anaesthetic can be given. A few operations, however, 
require special notice. 

In Tracheotomy an anaesthetic, though not absolutely necessary, is a 
distinct advantage, especially where it is desired to clear membrane from 
the trachea. The danger that it might set up a fatal spasm can be avo.ded 
by giving it gradually in a diluted state and by delaying the administration 
until the operator is quite ready. As preparation for any emergency, it is 
well to arrange the patient on a definite plan— e.g. on the back, with the 
shoulders and back of the neck supported by one firm pillow and a second 
smaller one under the occiput. In the event of a sudden spasm and cessa- 
tion of respiration demanding immediate operation, by pulling away the 
second pillow the head at once drops backward, making prominent the 
trachea without any lifting of the patient. This plan, though most useful 
in dealing with heavy adults, is equally valuable in children. 

Operations on the IVXouth. — In all operations on the mouth or pharynx 
it adds materially to the patient's safety, and to the chloroformist's comfort, 
to have the patient's head hanging downwards ; either hanging over the end 
of the table, or with the neck so extended over pillows that the vertex of the 
head rests on the table. The head must lie supported, or the weight of it 
hanging on the thorax tends to fix the chest. This position keeps the larynx 
quite free from blood, which, while it is fluid, will escape through the nostrils 
or mouth, or collect in the palate. A damp towel or bathing cap should be 
fixed around the head to keep the hair from being soiled. If the patient be 
properly arranged in this position, the risk of blood entering the larynx, even 
when the haemorrhage is excessive, is very slight, providing the patient is 
well ' under.' In all cases of bleeding from the mouth it is, we are convinced, 
safer to have the patient quite insensible and to keep the blood from the 
larynx by arranging the patient in a proper position, and by the use of 
sponges, than to trust to a semi-conscious patient coughing up the blood. 
In the latter case there is an equal risk that the blood may be sucked into the 
larynx, and with a struggling partially insensible patient it is more difficult 
to control any bleeding. 

As regards the selection of the anaesthetic, the fact that the operation is 
one involving the mouth or throat does not in itself confine the anaesthetic to 
chloroform. Mr. Warrington Haward has shown that ether may be used in the 



824 AncestJietics for Children 

operation for cleft palate, and ether is consftntly given in operations for post- 
nasal adenoid growths. 

In cleft palate, chloroform is the most convenient anaesthetic ; it should be 
given on lint until the patient is ' under,' and the administration continued by 
Junker's inhaler, by which means the operator can work continuously 
without being interrupted by the chloroformist. If respirations are feeble it is 
a good plan to apply the ether mask until moderately deep narcosis results, 
when it can be kept up with the Junker. 

In the operation for post-nasal adenoid growths, an anaesthetic 
(gas and ether or chloroform) should always be given. The patients are 
longer in becoming insensible from the interference of the adenoids with 
respiration. If the head is allowed to hang downwards and moderately 
deep narcosis is induced, the free haemorrhage is never any real trouble. 
In laryngoscopic examination, chloroform is useful for abolishing the fear of 
the patient ; but it will not always cause sufficient anaesthesia to permit of 
the larynx being manipulated through the mouth. In one case of laryngeal 
polypus in a child aged six years, under the care of Dr. Harris, we utterly 
failed to produce anaesthesia sufficiently deep to permit the growth to be 
removed by the mouth, even by combining the cocaine spray with the 
chloroform. 

In empyema cases chloroform is best. Care must be taken not to produce 
coughing by giving it too strongly at first, and the child must not be turned 
to the sound side, but may be sat up or turned on the diseased side, as 
recommended by Mr. Godlee. 

In cases of trephining the spine, chloroform should be given. The best 
plan, especially if there is paralysis of the intercostals, is to turn the patient 
right on to the face and support the body on pillows in the following way : 
the anterior iliac spines rest on a firm sand pillow, an ordinary thin pillow 
supports the chest, and the forehead rests on a second smaller firm sand 
pillow. By this means the operator gets free access to the spine, the abdomen 
is not pressed upon, and the diaphragm has full play, while the mouth and 
nose are supported some distance from the table, and the chloroform lint can 
be slipped under the nose as required ; any secretion flows easily out of the 
mouth. 

Operations on the Bladder. — In these cases it is important to have the 
patient ' under ' before injecting the bladder. If this is neglected the 
manipulations will most likely set up spasm of the glottis and straining, 
which will impede the inhalation of the anaesthetic and delay the production 
of anaesthesia. 

Accidents are of a similar nature to those which occur in adults, and 
should be treated on similar principles. As examples of the various kinds of 
accidents may be quoted cases in which an attempt is made to anaesthe- 
tise speedily a crying child, with the result that it is allowed to take several 
deep inspirations of a highly concentrated chloroform vapour, and so obtains 
a sudden overdose ; in other cases during deep anaesthesia the dangerous 
symptoms may be initiated by some sudden movement of the child. We 
have seen two cases of this class when the patient was deeply narcotised for 
the operation of cleft palate ; the sudden raising of the patient produced 
symptoms of syncope. In unprepared patients the embarrassment of 



Accidents under Ancesthetics 825 

respiration caused by a loaded stomach and the onset of vomiting gives 
much trouble. The patient breathes with difficulty, has spasm of the glottis, 
becomes pale and slightly cyanosed, has a feeble pulse, &c. ; most of these 
symptoms are relieved by vomiting. 

Apart from mechanical obstruction to respiration, accidents under 
anaesthetics are due to paralysis of the respiration or circulation or both. 
Treatment should be directed to restoring these functions. For this purpose 
it is futile to expect benefit from the effect of external stimuli, as these pre- 
suppose an irritability of the tissue which in severe cases is absent. The 
best remedy is artificial respiration so performed that pressure is made over 
the heart. This serves the treble purpose of getting air into the lungs, 
stimulating the heart, and keeping up the blood pressure. The supply of 
blood to the brain should be facilitated by having the head dependent, and 
an artificial circulation can to a slight extent be kept up by alternately raising 
and lowering the head. 

A number of drugs have recently been suggested as cardiac or circulatory 
stimulants under such circumstances — e.g. liq. ammon. fort, and acid, 
hydrocyan. by inhalation ; and ext. suprarenal capsules and nicotine by 
hypodermic injection. All these labour under the disadvantage that to be 
effectual a certain considerable degree of circulation must be present for 
their absorption and conveyance to the heart, &c, and this is as a rule absent. 
Of all, ammonia, from the method of applying it by inhalation and its power- 
ful effect as a cardiac stimulant, would seem most likely to be useful. 

The main reliance, however, must be placed upon efficient artificial 
respiration. The battery is useful only as a means of producing artificial 
respiration by stimulation of the phrenic nerves, and then it must be 
combined with compression of the chest. 



Calot's operation. — The revival of the practice of forcibly reducing the 
deformity resulting from destruction of the vertebral bodies by tuberculous 
disease must be briefly noticed, as the method has been to some extent 
employed in this country, and more largely upon the Continent and in 
America. 

The plan consists in straightening out an angular curvature by combined 
traction and pressure forcibly applied. That it is possible to reduce the 
deformity by this means in cases where active disease is going on, and even 
income instances where repair has taken place, there is no doubt. Whether 
the treatment is reasonable and justifiable is quite another question. When 
active disease is going on it can hardly be considered desirable to tear and 
bruise tissues already damaged by the attacks of tuberculosis, and run the 
risks of adding septic infection to the existing tuberculous lesion, nor must 
the dangers of causing tuberculous embolism be forgotten. But further than 
this a wide gap is necessarily made in the spine, and we have to consider how 
this is to be filled. The gap is lined with lacerated tuberculous tissue, 
and is filled with caseous material, recent blood clot, and probably 
fragments of carious or necrotic bone. These are not tissues likely to be 



826 Ancesthetics for Children 

effectual in satisfactorily filling up the chasm, yet they are, apart from a 
recurrence of the deformity and coaptation of the walls of the gap, the only 
material available for repair. 

Other objections to be raised against the plan are the dangers of injury 
to the spinal cord, of rupturing ' abscesses ' or collections of caseous materia!, 
of complete severance of the spinal column, and of lighting up a fresh out- 
break of the local tuberculosis. Such are the objections in theory to the 
operation. In practice the record of mortality and bad results, though very 
serious, is not hitherto so bad as might have been expected, but so far as we 
are aware no evidence is yet forthcoming that any repair or filling up of the 
gap by new bone takes place, and therefore we have no ground for believing 
that the restoration of shape will be permanent. 

The strongest argument in favour of the practice is that it is said to have 
been successful in some cases of paraplegia in relieving the pressure, but 
from what we know of the causes of paraplegia in spinal caries we cannot 
expect that this relief will be anything but exceptional. 

On the whole the practice is to be looked upon as wrong in principle, and 
too dangerous and uncertain to justify any further resort to it until it can be 
shown by a record of the cases already operated upon not only that the 
immediate and remote dangers are not great, but also that the improve- 
ment in position is permanent and the subsequent union of the bone secure. 
We have never been tempted to try the method. 



APPENDIX 



MODIFIED MILK, MILK LABORATORY 

THE WALKER-GORDON LABORATORY, 

626 MADISON AVENUE, NEW YORK 



Per Cent. 






REMARKS 




Fat 






Number of 

feedings 


Milk-Sugar 
Albuminoids 
Mineral Matters ... 


Amount at 

each feeding , 

Infant's age 


Total Solids 

Water 






Infant's weight 

Alkalinity 

Heat at 


% 




100 


00 


°F. 



Order for. 



Date, 



Signature, 



If the physician does not care to mention the especial percentages, he can ask for 
percentages which will correspond to the analysis of human milk, and he can then 
vary any or all of these percentages later, according to the need of the especial infant 
prescribed for. 



828 Diseases of Children 

REFERENCE lias been made (p. 48) to the milk laboratories established in Boston and 
other cities of the United States (also in London — the Walker-Gordon Laboratory) 
for preparing and modifying cow's milk in order to suit the varying needs of infants 
and children, both in health and disease. The physician writes a prescription 
stating the amount of fat, milk-sugar, proteids, &c, required in* the infant's food, 
and also the amount at each feeding ; the prescription is dispensed at the laboratory, 
and delivered at the house daily according to the directions given. One of the 
most important points in connection with these establishments' is that they have 
control of the milk from the first ; they keep their own cows, not purchasing any 
milk. Their cows are selected, fed, and cared for solely with reference to the 
employment of their milk for infant feeding, and the health of the animals is most 
carefully looked after. The milk is cooled at once to 40 F., and kept at this 
temperature till used. The food is sent out in separate feeding bottles, ready 
sterilized or pasteurized, and all the nurse requires to do is to warm the food and 
fit the india-rubber tube to the bottle when the infant is to be fed. 
A specimen of a prescription form is given on page 48. 

" Modified Milk." — Feeding of infants requiring a substitute for breast milk, 
American practice in the vicinity of milk laboratories has satisfied itself that 
" modified milk " is the most successful substitute feeding. In round statement, 
the composition of cow's milk may be set down as : 

Fats, 4%. 

Sugar, 4 %. 

Albuminoids, 4%. 

High average breast milk may be set down as : 
Fats, 4%. 
Sugar, J%. 
Albuminoids, 2 %. 

A low average may be set down as : 
Fats, 3 %. 
Sugar, 6 %. 
Albuminoids, 1 %. 

With these three sets of figures in mind, in a majority of cases the practitioner 
may "modify" the proportions of fat, sugar, and albuminoids to the needs of the 
child, changing the proportions according to the indications ascertained from ob- 
serving the nature of the passages and the general condition of the child. His 
orders for varied proportions he writes in a prescription. 

For a newborn, upon the third day, the beginning proportions may be tempo- 
rarily lower in percentages : 

Fats, 2 %. 

Sugar, 5 or 6 %. 

Albuminoids, 0.75$. 

Furthermore, with these figures in mind it is not impracticable with the aid of 
the Babcock cream-tester and the sugar solution to prepare approximately a modi- 



Appendix 829 

fled milk in a home-made laboratory. Such a laboratory is in use in two of the 
institutions for the care of young infants in New York. 

It is the earnest hope of the profession of America that the feeding of infants 
may be kept within the domain of physicians and without necessary reliance upon 
the made-up foods of commercial firms. Cow's milk when modified to the propor- 
tions of fats, sugar, and albuminoids found in breast milk offers at present the 
most available and practicable infant substitute feeding. For exactness in modi- 
fication a well-equipped laboratory, such as exist in Boston and New York, is 
requisite. 

Professor Rotch, of Harvard University, has taught the profession to think in 
percentages, and has brought to practical completeness, by the aid of the Walker- 
Gordon Laboratory, prescription writing and exact modifying of milk. 

The Pasteurization of Milk. — Pasteurization consists of two essential opera- 
tions of equal importance, (i) Sterilization at 68° C. = 155 F., followed by (2) 
rapid cooling to about io° C. = 50 F. The adoption of pasteurization has been 
due to our knowledge that such a procedure will destroy the pathogenic germs 
most feared in milk : those of typhoid fever, diphtheria, cholera, and tuberculosis, 
as well as the Staphylococcus pyogenes aureus, the Streptococcus pyogenes, the 
Coli communis and the Pneumococcus. It also destroys most of the non-pathogenic 
bacteria. On the other hand pasteurization does not produce those chemical changes 
in milk which are produced by sterilization at ioo° C. = 212 F., and which render 
the milk less digestible and less nourishing. 

A milk pasteurizer known as Dr. Freemaa's apparatus has recently been placed 
before the profession. This apparatus is simple and inexpensive and produces 
in the milk a fairly definite temperature of 6S° C. = 155 F., without the use of a 
thermometer, and is provided with a contrivance for rapid cooling. The apparatus 
consists of two parts : a pail, and a receptacle for the bottles of milk. The pail is 
an ordinary pail with a cover. Encircling the pail is a groove to indicate the level 
to which it is to be filled with water. The receptacle for the bottles of milk con- 
sists of a group of cylinders, each cylinder large enough to hold one bottle. 

In using the apparatus, the pail is filled to the level of the groove with water 
.and placed on the stove, the receptacle for the bottles of milk having been taken 
out. The bottles are filled with milk, stoppered, and placed in the cylinders of 
the receptacle. The space surrounding the body of the bottles in the cylinders 
is filled with cold water. When the water in the pail boils vigorously, the pail 
is taken from the stove and the receptacle containing the bottles of milk is placed 
in the pail. The pail is then covered and allowed to stand on a table or the floor 
for three-quarters of an hour. During this time an equalization of temperature 
takes place between the hot w r ater and cold milk. During the first ten minutes the 
temperature of the milk rises to about 68° C. = 155 F., and remains there during 
the following thirty-five minutes. At the end of three-quarters of an hour the 
cover of the pail is removed, the receptacle is elevated and the pail is placed in a 
sink under a faucet, from which cold water is allowed to run into the pail, thus 
replacing the hot water and cooling the milk. In twenty minutes the milk reaches 
about the temperature of the surrounding water and should be put in a refrigerator 
.until used. 



830 



Diseases of Children 





Fig. 214. — Dr. Freeman's Pasteurizing Apparatus. 

Pasteurized milk should be used only during the twenty-four hours following- 
pasteurization. 

Intubation.* — The views expressed on page 347 are not so favorable as those 
prevailing in America, Germany, France, and Hungary. Intubation is capable, in 
the hands of a skilled operator, supplied with the proper sizes and shapes of tubes, 
of meeting all emergencies which the advocates of tracheotomy claim for the cut- 
ting operation. This was true even before the adoption of the antitoxin treatment 
of diphtheria. The points to be specially considered are : 
When to operate. 
How " 

How to remove the tube. 
When 

Dangers and difficulties of operation, 
wearing. 

removal and thereafter. 
Advantages. 
When to Operate. — W 7 hen a progressive, unremitting dyspnoea, despite all pre- 
vious treatment, allows any considerable part of the posterior portion of the lungs 
to become non-inflated, when the labored breathing begins to produce sensible 
exhaustion, intubation is to be performed promptly. 

How to Operate. — Wind the child from chin down in a light blanket, shoulders, 
arms, and hands included. Pin the blanket closely about the neck, and yet do not 
make a bulky roll to interfere with depressing the introducer handle. In this way 
the elbows are pinioned to the side and the hands are held across the child's abdo- 
men. 

The nurse sitting upright, not leaning back, should grasp the child's elbows 
firmly, outside its winding blanket, of course, and clasp the child's legs between 
her knees, making sure she twines her own about the legs of the child. Some 
prefer to stand the child upon the nurse's lap, she (the nurse) clasping her arms 



* Extracts from a paper read by the American Editor, before the British Medical Associa- 
tion, Bristol, England, 1894. and published in Brit. Med. Journal, Dec. 29, 1894. 



Appendix 831 

about its knees. All these precautions are to secure the child in a firm grasp, to 
immobilize it without interfering with the expansion of its chest, and may be taken 
without causing any apprehension or excitement. The position of the child should 
■be as though it hung from the top of its head. 

The physician assisting should stand behind the chair of the nurse, grasp the 
child's head between his hands, hold it firmly, and when the gag has been inserted 
include it within his grasp to insure its firmness and steadiness. The operator, 
seated or standing squarely facing the child and nurse, inserts the gag, opens the 
mouth widely, and gives the handle into the keeping of the assistant. The intro- 
ducer, armed with the proper-sized tube, is supposed to be threaded and at hand. 

Next he inserts his index-finger, hooks up the epiglottis, crowds his finger to 
one side, passes the tube past it till it engages in the chink of the glottis, elevates 
the handle, gently passes the tube down till the head is within the box of the lar- 
ynx and the introducer lies crowded upon the tongue. He then, with the trigger, 
loosens the obturator, holds the tube with the left index- finger while withdrawing 
the obturator, and with a gentle thrust presses the tube's head well into the larynx 
and removes the finger and gag. Just here let me emphasize what is stated above 
— keep the introducer in the middle line ; otherwise the obturator will pinch in the 
calibre of the tube and drag the tube with it as it is withdrawn. 

The handle of the introducer should be held most lightly between the end of 
the thumb and the fingers. In this way it is impossible to use enough force to 
make a false passage. The lines and angles must be maintained to insure quick 
intubation. If on the first attempt the tube is not successfully placed in the lar- 
ynx it is better to make repeated short attempts than prolong one. 

Having placed the tube in the larynx, there will be rattling in the tube on first 
respiration and subsequent cough and expectoration. A vigorous cough argues 
well for the sensitiveness of the parts, and for evacuation of accumulations below. 
The gag is removed as soon as the tube is in place, but not so the thread ; it must 
remain till it becomes evident that all obstruction to breathing has been overcome, 
and no partially detached false membrane is in the trachea below the tube. The 
thread at first acts as an inciter to cough, which is desired ; ordinarily, ten minutes 
are sufficient time. 

How to Remove the Tube. — Place the child in the position for intubation as 
■described above. Thrust the left index-finger past the epiglottis, hook it up, rest the 
tip of the finger upon the two arytenoid cartilages and carry the extractor point to 
the end of the left index-finger at the pulpy portion generally regarded the most 
delicately tactile. The situation is then as follows : — The finger-tip upon the 
arytenoid marks the posterior boundary of the glottis in the median line. Now, 
if the extractor point be carried along the median line to the end of the finger and 
the handle be elevated, the .point will naturally be pried foward from the end 
of the left index-finger on the arytenoids, into the aperture of the tube. Occasion- 
ally cases are found in which the epiglottis hugs so closely the head of the tube 
that it is very difficult to raise it and keep it out of the way. This is liable to 
occur, especially in ascending croup, in which the epiglottis is not always involved 
in the diphtheritic process. In such cases the extractor would be guided better 
with the left index-finger at the side, as in intubation. The guard screw of the 



832 Diseases of CJiildren 

extractor-lever should be carefully set to avoid injury to the tissues in case the 
extractor jaws should be opened by mistake in the soft parts instead of in the 
tube. Many operators, both in Germany and America, leave the thread attached 
throughout the whole time, and occasionally a tube is coughed out after the swell 
ing releases its grip. So in actual experience one is not called upon to extract 
so often as to intubate. The fact remains that extubation is more difficult. 

When to Re )7tov e the Tube. — This depends on the age of the child and duration 
of the disease before intubation became necessary. The older the child the earlier 
the tube can be dispensed with. Estimating the maximum of the disease to be 
seven days, five days' wearing the tube is considered, on an average, sufficient. 
The use of antitoxin has diminished the time of sojourn of the tube to forty-eight 
and often twenty-four hours. 

Dangers and Difficulties of the Operation. — In the hands of an experienced 
operator there are practically no da7tgers to life at the time of operation. 

A few authentic cases of pushing down membrane before the entering tube 
have been recorded. Expert intubation according to latest practices presupposes 
that the thread has been left attached, and therefore easy immediate removal is 
possible. This experience with loose pseudo-membranes occurs more often late in 
the disease, and in reintubations. 

To the inexperienced there are many dangers : (1) asphyxia from prolonged 
attempts ; (2) laceration of the parts, false passages, etc. The explanation 
usually given to those two most common accidents is " pushing down false mem- 
brane." So called syncopal attacks are simply lesser attacks of asphyxia. Con- 
vulsions are recorded, and instruments have been broken in intubation. 

An experienced operator may encounter two difficulties : 

1. The point of the tube may enter one of the ventricles of the larynx. This 
is not common, for the original disease usually fills and obliterates these cavities. 
Such obstruction, however, does occur. It may readily be seen how an inexpert, 
sure that his tube and handle were exactly in the middle line, might force his tube 
into the tissues of the neck. He certainly has but to remember the cardinal 
points of advice, and he will use most gentle pressure ; he need but look at the 
light introducing instruments to appreciate that they are for delicate work. 

2. The second difficulty or obstruction that an experienced operator may meet 
in intubation is subglottic stenosis — or what is so often described as "oedema." 
The narrowest part of the respiratory ways is the cricoid ring. This, fact, so far 
as I know, came to light for the first time in Dr. O'Dwyer's early investigations 
in intubation. If the head of an intubation tube be forcibly crowded down from 
above, it may pass the vocal bands, and yet resist all effort at the cricoid ring. 
Given a resisting cartilaginous ring lined with mucous membrane, we have the 
very elective conditions for stenosis. Fortunately, the swelling and infiltration 
are not often extensive enough to cause serious obstruction, but may be. Opera- 
tors come upon cases where the properly selected tube surely passes into the 
larynx, and yet encounters resistance — even " creeps back," as someone says, 
" like an oiled cork in a bottle." If one is sure of the diagnosis, and a proper 
size fails, a smaller tube may, with moderate pressure, be introduced. This is the 
only condition where force is justified in intubation. 



Appendix 



833 



Dangers and Difficulties of Wearing. — 1. The tube may become obstructed 
by loosened plaques of false membrane. This constitutes the one important 
danger in wearing an intubation tube. It is easy to understand that large plaques 

may become loosened and detached in the 
trachea, especially after several days of the 
disease. 

A detached plaque may act like a valve at 
the tube's lower end, closing on expiration, 
opening on inspiration till the lungs become 
quite distended from accumulated air. 

At this point let me interject the symptoms 
of loose membrane : — (1) croupy character of 
cough (tube being in) ; (2) flapping sound ; (3) 
most important, sudden obstruction to outgoing 
air, especially during coughing. 

Most continental operators loop the thread 
about the ear, protecting it along the cheek with 
rubber adhesive plaster, and leave it throughout 
the wearing of the tube. This is advisable out- 
side of hospitals, with beginners, and in case 
loosening pseudo-membrane is suspected in the 
trachea. Possibly mucus may gradually collect 
in the tube, of such a tenacious quality, espe- 
cially in mouth -breathers suffering from high 
temperature, that it becomes an embarrassment 
or even danger. 

Short Tubes {loose membrane or foreign-body 
tubes.) — They are short, hollow cylinders of 
large calibre — short enough not to push down 
the tracheal membrane, yet long enough to reach 
below the cricoid stenosis and large enough to 
permit masses to pass through them. 

Occasionally a long tube loosens the upper 
attachment of a tracheal cast and crumples it 
into a wad below the end of the tube. The 
usual result is, as would be expected, apncea. 
Immediate removal of the tube is commonly 
followed by either expulsion of the cast or other 
disposal of the mass in the comparatively large 
trachea. At this point, when the long tubes have failed to give relief, the short 
cylindrics become of temporary service. 

These tubes are of various sizes, seven in number. Since they have no reten- 
tion swell it is necessary to use the largest size possible, wedging it into the larynx, 
and for obvious reasons in the line of pressure, not leaving them more than a few 
hours in place. They require a special introducer with long curve in order to carry 
the short tube well through the cricoid constriction before withdrawing the obturator. 




Fig. 215.— Short large calibre tubes 
(loose membrane or foreign-body 
tubes). 



834 Diseases of Children 

In short, to allow the expulsion of loose membrane from the trachea, the largest 
possible hollow cylinder is passed through the narrowed larynx, allowed to remain 
for a little, and removed as soon as the resulting cough has expelled the foreign 
body requiring its insertion. 

2. Ulceration from too large a tube making pressure within the cricoid ring, 
and ulceration at the lower end of the tube. The former can be of a serious 
nature, destroying the cartilage ; the latter is superficial and of little import. Ul- 
ceration within the cricoid is due to improper size ; ulceration below to improper 
construction of tube. 

Properly constructed tubes are difficult to describe, more difficult to secure from 
a maker, even if a most faithful and conscientious servant. But one maker in 
this world has succeeded in making tubes that embody all the ideas of the 
inventor. 

Feeding an Intubated Patient. — There is one disadvantage after operation : 
feeding is difficult. The larynx is sore. Many times it is sorer because of the inex- 
perience of the operator. The less the larynx is bruised in intubation, the less the 
child will dread the clasp of the pharyngeal muscles in the act of deglutition. The 
fact remains that there is more or less difficulty in swallowing, both from pain and 
cough. The latter arises from fluids entering the trachea, though many patients 
acquire the accomplishment, and learn to swallow very well. The method of feed- 
ing adopted by Dr. Casselberry, of Chicago, has very much relieved the situation. 
The child is inclined, head down, so that it swallows up-hill, and any fluid that 
may get into the tube in the act of deglutition quickly gravitates out again. The 
directions are as follows : — Place the child across the nurse's lap, bend the head 
well down, and feed either with a spoon or through a nursing bottle. At first 
these patients object, but when they learn that by so doing they can swallow with- 
out coughing they give no further trouble. 

Medication can be continued after intubation as well as before. 

Danger of Removal and Thereafter. — If the tube is removed on the fifth day 
in a case having an average fair course, there is little or no danger. The operator 
should remain half an hour. If in this time there has been coughing and clearing 
of the throat and trachea and no loose pseudo-membrane remains, and no dyspnoea, 
there will be no sudden urgent necessity of rapid reintubation. Even yet it is 
deemed desirable to be within easy call for some hours. 

I once considered I had on an average four hours' leeway, but exceptionally 
prompt aid was needed sooner, and a few cases needed reintubation twelve and 
twenty-four hours afterwards. Whether, pressure removed, the mucous membrane 
becomes quickly congested, or whether muscular spasm sets in, or membrane 
reforms, I know not, but I have learned to respect the emergency of the first 
twelve hours after removal of the tube, especially if it be a premature removal. 

Retained Tubes {Laryngeal Canulce). — Rarely it is necessary to reinsert a tube 
many times. The child may get along half a day or two days and yet require the 
reintroduction. If the tube is not of proper anatomical conformity it may cause 
granulations about the head. To relieve this and cure the condition, a special 
tube has been devised, naving a prolonged or built-up head. (See Fig. 216.) It 
rides above and causes pressure upon the granulations, with consequent absorption. 



Appendix 



835 




Fig. 216.— Built-up head 
for granulations. 



Finally, not to recapitulate the literature of the subject, I may mention advan- 
tages. First of all, parents will consent. 

It is a bloodless operation ; no cutting, no anaesthetic, 
and this means much to the friends. It is quickly per- 
formed, requires no trained assistants or trained attend- 
ants (it is trained operators that are needed). The air 
inspired is warmed and moistened through natural pas- 
sages. Results are equal to or rather better than those 
of tracheotomy under similar circumstances, whether in 
hospital or outside. 

Finally, since the. successful employment of antitoxin 
treatment for diphtheria the average duration of laryngeal 
stenosis has been so shortened that there seems no longer 
any ground for contention as to which is the preferable 
method of tiding past the urgent symptoms of dyspnoea. 
As Professor von Ranke, of Munich, proclaimed to the 
British medical profession in London, " the time has come 
when it should be upon a man's conscience to leave a 
scar upon a child's neck, for, with the employment of 
healing serum there remains no excuse for tracheotomy 
in diphtheria." 

Rickety Deformities (p. 208).— The transverse thoracic furrow, with the pro- 
jection of the ribs forming the lower edge of the thorax, so very common in severe 
■ cases of rickets, is often associated with more or less kyphosis of the dorso-lumbar 
spine. All of these conditions can be very much improved by applying a light steel 
spinal brace to hold the spine erect and draw back the shoulders. Over this brace 
is applied a corset made of drill, which exerts pressure on the lower projecting ribs 
only, and limits abdominal respiration. Thoracic respiration is then developed by 
inspiratory exercises. The result will repay the surgeon for the persistent work 
necessary, as the writer has seen in a number of cases. 

Curvature of the neck of the femur, Coxa Vara (p. 211). — A number of cases of 
this deformity have been recorded here already by Curtis, 'Whitman and others, and 
it seems likely that when more attention is directed to the condition our experience 
will be similar to that of Hofmeister and other German surgeons, who have found 
that the deformity is not very uncommon. It is produced by the weight of the 
body and diminished resistance in the bone. It is observed in two-thirds of 
the cases during childhood, and in the remaining third at the age of puberty. The 
affection starts with pain in the hip and limping ; at first in consequence of a long 
walk or great fatigue ; later, after a moderate walk ; ultimately no work is possible. 
Function is especially impaired in bilateral cases. The disease runs its course with 
periods of remission and exacerbation. In two or three years the pain ceases, and 
there remains as a final result an actual shortening of the limb, the great trochanter 
being above Nekton's line. There is diminished abduction and inward rotation. 
The limb rests in a position of outward rotation, and the patient can produce 
exaggerated rotation in this direction. The walk is in consequence characteristic, 
and when the patient wants to assume a kneeling position he is obliged to cross 



836 



Diseases of Children 



his legs. The exact point of this incurvation is on the under side of the neck and 
a little posteriorly, which explains, the elevation of the trochanter and the outward 
rotation of the limb. A large number of so-called obscure cases of coxitis are 
really this affection. The diagnosis is important with reference to the question of 
early excision, sometimes recommended in hip disease. Rest will soon stop the 
pain. Then continuous extension, massage, and exercise may benefit some cases. 
The neck of the bone should certainly be relieved from the weight of the body by 
means of a hip-splint or axillary crutches, during the progressive stage. No 
promises should be made of diminishing the amount of curvature of the bone 
found when treatment is commenced. 

Shaffer (p. 210) favors supporting the kyphotic spine in severe cases of rickets 
during the progressive stage in order to secure bone-growth in the normal planes. 
In this way not only can we readily, and without discomfort, correct the evident 
kyphosis, but also correct or prevent the development of lateral curvature, since 
many cases of this curvature are dependent upon a rickety condition and develop 
very early in life. 

The splint most commonly used in New York for knock-knee and bow-legs is 
shown in Fig. 217. The jointed apparatus is efficient, since leverage is applied 
whenever weight is borne. It also favors muscular development, and allows a 
more graceful gait. A pelvic band may be added to control the position of the 
feet if required. These braces are somewhat expensive, but at ,the New York 
Orthopaedic Hospital this objection is met by allowing the patients to pay for 
them on the instalment plan. The Knight brace (Fig. 218) for bow-legs, and 
the Thomas knock-knee brace, are also largely used. These deformities can be 
more quickly corrected if, in addition to the application of the splints, the limbs 
be bent by manual pressure towards their normal position several times each day. 





Fig. 217.— New York Ortho- 
paedic Hospital Brace for 
Knock-knee and Bow-legs. 



Fig. 



—Knight's Bow-leg 
Brace. 



Fig. 219.— Boston Children's 
Hospital Brace for Bow- 
legs. 



Appendix 837 

The pressure should be as great as the child will bear without crying, and should 
be maintained a minute or two, then relaxed and reapplied several times. In the 
very slight grades of deformity these forcible intermittent pressure-exercises may 
be sufficient to cure without the use of braces. 

In the Children's Hospital in Boston, the apparatus in common use for bow-legs 
(Fig. 219) is a light but rigid steel upright, jointed at the ankle, attached below to 
the sole-plate of the shoe. It runs up the inside of the limb nearly to the origin of 
the adductor muscles and is then bent forward and upward and curved to fit into 
the groin and come up as far as the posterior part of the dorsum of the ilium. 
Leather pads opposite the greatest convexity of the curve draw the limb over to the 
upright. For knock-knee a similar apparatus is used, but is applied on the outer 
side of the limb, and at the level of the trochanter the upright is bent backward 
and upward to lie against the upper part of the buttock. By fastening the upper 
ends together the position of the feet can be controlled. 

For extreme deformity powerful correcting apparatus have been devised by 
Shaffer {American Journal of Obstetrics, etc., vol. xiv., No. iii.). 

Whether a case will require operative treatment depends more upon the flexibil- 
ity of the bones and the laxity of the ligaments than upon the age of the child or 
the amount of deformity. Anterior curvatures of the tibia have seemed to the 
writer the most intractable to mechanical treatment, and generally require an oper- 
ation for their correction (see also Bradford and Lovett, " Orthopaedic Surgery," 
p. 682). 

In America, Macewen's operation (p. 221) for genu-valgum is chiefly em- 
ployed. MacCormac's modification, in which the chisel is used upon the outer 
side of the limb and a green-stick fracture produced on the inner side, is also 
thought well of. In any case the practice is to wait until the active stage of the 
disease is past before operating. The saw is almost never used here. In general 
osteoclasis is not so much in favor as osteotomy. Rizzoli's or Grattan's osteoclasts 
are those most used. 

The ambulatory treatment of fractures and osteotomies as recommended by 
Bardeleben, Korsch, Albers, Krause, Dollinger, etc., has not as yet received, 
enough attention in this country to report upon its usefulness. 

Lateral Curvature of the Spine. Early Onset (p. 223). — In a study of two 
hundred and twenty-nine cases, Ketch (New York Medical Record, April 24, 1886) 
found (1) that this curvature is principally a disease of childhood, and may be either 
congenital or acquired ; (2) that puberty, except as a concomitant occurrence, which 
may by its attendant circumstances increase it or bring it into unusual prominence, 
has no direct causative influence ; (3) that lateral curvature should be looked for 
early in life, and as a factor in treatment the early inspection of children's spines 
becomes most important toward the prevention of the deformity. 

Bradford and Lovett also ("Orthopaedic Surgery," p. 106) recognize its appear- 
ance at an earlier age than is usually supposed. 

Treatment (p. 223). — Shaffer relies largely in cases of rotary lateral curvature 
on an exercise partly active partly passive. Pressure is made by the operator's- 
hand just under the greatest convexity, in a direction inward, forward, and up- 
ward, the opposite shoulder being elevated at the same time. The patient bends- 



838 Diseases of Children 

over the hand exerting the pressure and untwists the spine as much as possible. 
The counter-pressure is exerted below by the weight of the pelvis and limbs, and 
above by the weight of the upper part of the thorax and head, increased, if neces- 
sary, by pressure from the operator's hand, which is being used to elevate the 
shoulder opposite the projecting ribs. In giving the exercise the patient swings 
obliquely forward and backward, and at every backward swing the pressure is ap- 
plied after the body passes the perpendicular. The patient is also encouraged to 
swing from rings hung at unequal heights, so as to overcorrect the drooping shoul- 
der. These exercises are given once, twice, or three times a day for from five to 
twenty minutes. Sayre {New York Medical Journal, November 17, 1888) advises 
the following movements, which are very similar to those of Bernard Roth ("Treat- 
ment of Lateral Curvature of the Spine," London, 1889) and are, with modifica- 
tions, those most generally used in the United States. The various exercises are 
repeated three times each at the commencement and later on a greater number of 
times. 

" The patient lies prone, the arms at right angles to the trunk, palms down, face 
turned to the convex side, and the back as straight as possible. The patient supi- 
nates the hands, throws the scapulae well back, raises the hands from the floor 
and lifts the trunk, while the surgeon holds the feet down. The breath should 
not be held during any of these exercises, but the patient should breathe naturally. 
If necessary to secure this, make them count out loud while exercising. 

With hands behind the head, the patient raises the elbows from the floor, and 
raises the trunk as before, the feet being held by the surgeon. 

With the hands behind the head and the elbows raised, the body is swayed to- 
ward the convex side, the patient trying to "pucker in" the bulging ribs and not 
to bend in the lumbar concavity. The feet are fixed as before. 

With the arm on the side of the convexity under the body, the other arm over 
the head, the heels fixed, the patient raises the trunk from the floor. 

Sometimes the arm on the side of the concavity is put on the opposite buttock, 
while the patient raises the trunk. Sometimes the arm on the convex side is 
put on the buttock, and in cases of marked lordosis, with great stooping of the 
shoulders, both hands are put on the buttocks while the patient raises the trunk. 

The patient now lies on the back, arms at the sides, palms up, and lifts first 
one foot in the air, while the surgeon makes resistance graduated to the patient's 
power ; repeated, say, five times. The same is done with the other foot, and then 
with both. The feet are next separated and then brought together once more while 
the surgeon resists. Each leg then describes a circle, first from within out, then 
from without in. 

If there is special weakness at the ankles, with a tendency to flat-foot, the pa- 
tient flexes the foot and extends it against resistance, and turns the sole of the foot 
toward its neighbor, the surgeon resisting, and it is then forcibly everted again by 
the surgeon, the patient resisting. 

The patient now lifts the arms from the sides, passing perpendicularly to the 
floor till they are stretched as far beyond the head as possible, and then, going at 
right angles to the trunk and parallel with the floor, returns them to the sides, 
palms up. 



Appendix 839 

While the heels are held, the patient rises to the sitting position, hands at the 
sides ; then she rises from the floor with the hands behind the head and the elbows 
at right angles to the trunk. 

The patient now stands with the heels together, toes turned slightly out, hands 
behind the head, elbows at right angles to the trunk : then rises on tip-toe, bends 
the knees and hips, keeping the back as straight and erect as possible, and rises up 
once more. With the arm on the concave side, high above the head, the arm on 
the convex side at right angles to the body, she rises on tip-toe, bends the hips, 
knees, and ankles so as to squat, then rises and stands. All this time care must be 
taken to push the body as straight as possible, and gradually educate the patient to 
hold it so without wiggling during these movements. 

Let the patient practise walking in these positions, both on the flat foot and _ 
tip-toe, and also step high as if walking up-stairs. With the palm of the patient's 
hand on the convex side against the ribs, pushing them in, the hand on the con- 
cave side, she pushes a slight weight up in the air, while the body swings so as to 
straighten out the curves. 

Sit behind the patient, fix her thighs with your knees, while she holds both arms • 
above the head and bows toward the floor, keeping her knees stiff while you keep 
her ribs as straight as possible with your hands. 

With the arm on the concave side across the top of the head, and the arm on 
the convex side around in front of the abdomen, the patient bends to the convex 
side through the ribs, and not through the waist. 

The patient sitting with the back toward the surgeon, the latter pushes one 
hand against the most projecting part of the convexity, and, with the other hand 
passed under the shoulder of the concave side, straightens out the curve as much 
as possible, the hand on the "bulge" acting as a fulcrum in straightening the 
curve. 

The patient sits on a stool in front of the surgeon, who fixes the pelvis with his 
knees. The patient then twists the projecting shoulder to the front while the sur- 
geon holds the elbows, which are at right angles to the trunk, the hands being be- 
hind the head, and makes resistance. In the same position the patient swings for- 
ward and back, swinging through the hips, keeping the back stiff, and not bending 
in the waist. 

The patient pushes in the ribs on the convex side with the hand, and pushes up 
with the hand on the concave side, the same as when standing. She also lifts the 
arm on the concave side up at right angles with the body while holding a weight. 

In cases of round shoulders, windmill motions of both arms and to-and-fro 
movements of the head against resistance are advisable. 

The patient lies prone on the couch, all the body above the waist projecting 
from it, while the surgeon holds the heels. With the hands behind the head, the 
elbows thrown back, the body is bent toward the floor, then raised up ; later on, 
resistance is made by the surgeon. The patient lies on the concave side and 
rises up laterally. The patient lies with the convexity on the edge of the couch, and 
hangs off as far and as long as possible. 

One of the best exercises for removing the curve is for the patient to place the 
head in a collar attached to a cross-bar above the head, suspended from the ceiling, 



840 Diseases of Children 

by a compound pulley and rope. The patient now grasps the rope as high up as 
possible, and pulls up hand over hand until the toes just touch the floor. While 
hanging thus she takes three deep, full, slow inspirations and expirations. While 
she is hanging thus the surgeon corrects the rotation by pushing the ribs with one 
hand while he steadies the pelvis with the other. 

Another good thing is for the patient to have a belt passing around the pelvis, 
with a handle at each side. Holding these in the hands, she straightens the arms 
out, and the spinal column is thus stretched and straightened much in the same 
way as by self-suspension. 

The patient stands bent forward as if playing leap-frog, her hands on a chair, 
while the surgeon, with one hand under the shoulder on the convex side and one 
hand on the projecting ribs, corrects the rotation. It is advisable to steady the 
patient with the knee while doing this." 

Teschner has lately (Annals Surg., Aug., 1895) advocated the system of exercises 
used by the German athlete Attilla. This consists of a long series of the usual 
light dumb-bell exercises with poising of the body in various positions. These 
are followed by swinging and raising at arms' length above the head very heavy 
dumb-bells and bars. The object being to thoroughly tire out the weak muscles, 
on the ground that in this way only can they be fully and rapidly developed. 

Rachilysis and other very forcible methods of reducing rotary lateral curvature 
have not found thus far much favor in this country. 

Apparatus for Lateral Curvattire. — The supports used in the United States 
for lateral curvature are employed to retain an improved position and to relieve 
pain and weakness. Muscular development is at the same time encouraged in 
every way, the idea being to lay aside the apparatus as soon as the muscles have 
been made strong enough to retain the improved position. Some cases seen late 
in the disease cannot be improved in respect to deformity, and yet feel much more 
comfortable if properly supported. Others, again, from cardiac or pulmonary com- 
plications, cannot take the exercises required, and the ultimate results are better 
when mechanical treatment is carried out. In order that the appropriate exercises 
may be given all supports must be removable. Probably the plaster-of-Paris jacket 
applied with suspension is more generally used than any other method. Sayre 
moulds the patient's figure with his hands as much as possible after the jacket is 
applied and before it hardens. He uses the jacket as an adjuvant and only in 
those cases where the patient is not able to retain by voluntary effort so good a 
position of the body as can be obtained by partial self-suspension by means of a 
pulley and head-swing. Bradford uses, in cases which are markedly resistant and 
in growing patients where rigidity is not complete, permanent plaster-of-Paris jack- 
ets, exerting a correcting pressure upon the abnormally prominent ribs, while the 
jacket is still soft, from behind forward and from before backward, by means of a 
screw force extending from a circular steel ring which is placed around the patient's 
trunk temporarily while the jacket is being applied. 

Steele recommends a raw-hide jacket. Phelps uses an aluminium corset (Trans. 
Amer. Orthop. Assoc, 1893), or one of wood-shavings (Waltuck Method, New 
England Medical Monthly, February, 1892), and Vance one of paper. Roberts 
("Transactions Ninth International Congress," vol. iii.) has devised a wire corset, 



Appendix 841 

■designed to exert a continuous elastic pressure. Shaffer uses a light steel appa- 
ratus, adapted to exert pressure in the desired direction, at the same time allowing 
some antero-posterior movements of the trunk. Exercises are systematically used 
in addition. 



DISEASES OF THE BONES. 

Ununited Fractures (p. 645).— Ridlon, in cases of delayed union«in fractures 
of the leg (New York Medical Record, January 31, 1891), following Thomas, advo- 
cates the use of the latter's caliper splint, but so modified as to permit of no motion 
at the ankle, and with a laced leather leg-sleeve added. 

The advantages claimed over plaster-of- Paris are better immobilization, and no 
constriction at the seat of fracture. The apparatus allows the patient to go about 
during treatment and permits the production of cedema by damming. 



DISEASES OF THE JOINTS. 
Origin (p. 660). — Northrup has given some instructive records of autopsies 
bearing on this point (New York Medical Journal, February 21, 1891). He 
found that the primary seat of tubercular infection was in the bronchial lymph- 
nodes in a great majority of cases. In 125 cases examined, 34 had too extensive 
lesions to determine which was primary ; 20 had the oldest lesion in the respiratory 
tract; 42 had cheesy masses in bronchial lymph nodes only, more recent tubercules 
were found in lungs and elsewhere. In 9 all the tubercular process was confined 
to these nodes and the lungs. In 13 it was limited to the nodes alone. 

Abscess in Joint Disease (p. 660). — The treatment of tubercular abscesses 
has always been a matter of debate. Townsend (Trans. Amer. Orthop. Assoc, 
iSgi) has found that nearly fifty per cent, of a large number of cases which he col- 
lected and analyzed were by repeated aspirations relieved and the abscess eventu- 
ally disappeared. Some surgeons incise and drain them as soon as fluctuation is 
found, whether they have become infected or not. 

In a paper on " Operative Interference in Abscess of Chronic Tubercular Disease 
of the Joints," read before the New York Academy of Medicine, in October, 1895, 
Shaffer said that he waited until there were severe general or local symptoms due to 
the abscess itself before he incised it. So long as we knew of its existence by 
sight and touch only, we were justified in ignoring it. He found that many 
of them disappeared, and few, if any, gave rise to trouble, and that those which 
opened spontaneously uniformly did well. In the adult and adolescent, an invariably 
favorable prognosis could be given if the non-operative method be adopted together 
with efficient mechanical treatment, whereas the prognosis was not so certainly good 
if the abscess were operated upon. The efficiency of the mechanical treatment 
was, of course, very important. There are cases in which mixed infection occurs 
and in which there may be symptoms indicating a minor degree of septicaemia. 
Even here Shaffer advised waiting awhile before incising. If the joint is properly 
protected, the urgent symptoms will probably subside. If they persist, a free in- 
cision must be made. Ordinarily the abscess should be allowed to open spontane- 



842 Diseases of Children 

ously, then simple external dressings are applied and the parts kept clean with per- 
oxide of hydrogen or bichloride of mercury. The ultimate recovery of the joint 
is better under the non-operative treatment than after incision of the abscess. 

Dane has endeavored to find a method of discovering whether these cold ab- 
scesses have become infected or not, and has published his work in a recent number 
of the American Journal of the Medical Sciences. His conclusions are : 

1. Most cases of tuberculosis of the bones and joints do not decrease the 
number of the red corpuscles in the blood. 

2. They do, however, affect the percentage of haemoglobin, giving rise, in fact, 
to a mild degree of chlorosis. 

3. The leucocyte count seems to have no special relation to the tempera- 
ture. 

4. High counts, especially in hip disease, point to the probability that there is 
or shortly will be abscess formation, but low counts do not preclude the presence 
of pus, especially in long-standing cases. 

5. Where an abscess is found in the face of a low leucocyte count, the pus 
from it is sterile, that is, does not contain pyogenic organisms; it does often contain 
tubercle bacilli. The case is generally one of long standing. 

6. In the presence of an abscess a low leucocyte count indicates the absence 
and a high count the presence, of a secondary infection with pyogenic organisms. 

7. Cases where at the primary operation the pus has proved sterile, generally 
show an increase in the leucocyte count, and especially in the differential count, 
where the wound becomes infected with the pyogenic organisms. 

8. High total leucocyte counts do not always affect the differential count. 
Dane in these investigations used the Thoma-Zeiss apparatus. The red pipette 

was diluted 1-200 with " Toison's solution," and the white in a separate pipette 
1-100 with 3% acetic-acid solution and a little methylene violet. The dry slides were 
hardened in benzine, and stained with Ehrlich's triple stain. 

Case I. — Boy six years old. Hip disease, one and a half years' duration. De- 
veloped an abscess about four months previously. Entered with large fluctuat- 
ing tumor both in front and behind joint. Operation showed §v greenish puri- 
form material. Head of bone nearly separated, and rim of acetabulum much 
roughened. 

Blood count : 

Erythrocytes 6,096,000 

Haemoglobin 75^ 

Leucocytes 6,756 

Lymphocytes 28$ 

Large mononuclear and transitional forms 12$ 

Polynuclear neutrophils 58$ 

Eosinophiles 2% 

Pus proved sterile from pyogenic organisms. 

Case II. — Girl three years old. Hip disease, seven months' duration. Abscess 
for two months. Large fluctuating swelling on anterior aspect of thigh over great 
trochanter. Operation gave %vi pus, and showed a sinus leading into the joint, 
which was not much disintegrated. 



Appendix 843 



Blood count : 

Erythrocytes 3,744,000 

Haemoglobin . 65^ 

Leucocytes 41,369 

Lymphocytes 14$ 

Large mononuclear and transitional forms 5$ 

Polynuclear neutrophils . 8i# 

Eosinophiles 0% 

Pus showed the presence of Staphylococcus pyogenes aureus and Staphylococcus 
pyogenes albus. 

Mechanical treatment. Shoulder (p. 664). — To apply extension at the 
shoulder Shaffer iises an axillary crutch, to which is attached an extension-bar run- 
ning down the inner aspect of the arm, and terminating in a band which half 
encircles the arm. Adhesive straps are applied and fastened to this band, and the 
extension-bar lengthened as required. 

Townsend (Trans. Amer. Orthopedic Assoc, vol. vii.) claims that the usual 
termination of this disease under mechanical treatment is ankylosis more or less com- 
plete, as a rule limiting the ability to raise the arm from the side to about one-third 
or one-fourth the normal amount. This loss of function is a serious matter in 
many cases, and only such work can be done in severe cases as requires but little 
force, and such as can be supplied by the forearm alone. When the patients can 
get the hand to the head to feed and dress themselves the condition is not so seri- 
ous. Townsend claims that after partial or complete excisions much more freedom 
of motion can be obtained in most cases. Rejecting the statistics of pre-antiseptic 
days the operation does not appear to be dangerous. The joint is easy of approach; 
and in a large majority of instances the disease is located in the head of the 
humerus, and can thus be entirely removed. By partial operations and the sub- 
periosteal method the growth of the limb should not be much affected. In regard 
to mechanical treatment Townsend says that in no case that he had treated was 
this method given a fair trial, but that from careful reading and the examination 
of some patients supposed to have been subjected to careful mechanical treatment 
he had been led to the belief stated above. 

Mondan and Audry (Revue de Chirurgie, 1892) found as the results of thirty- 
two excisions, all done on patients near adult life, that the starting point of the 
disease was in twenty-nine cases in the bone, in one doubtful, and in three it was 
clearly synovial. In twenty-three of these cases the disease originated in the 
humerus, in four in both the scapula and the humerus, and in one in the scapula. 

Elbow (p. 664). — To immobilize the elbow Myers uses a splint formed by 
wires that follow the upper and lower borders of the hand and forearm, the an- 
terior and posterior borders of the arm, and then descend on the side of the body 
to the waist-line ; a laced sleeve holds the hand and forearm, and another the 
arm. Thoracic and abdominal straps hold the splint firmly against the body. 
This controls the short limbs of children well. 

Wrist-joint. Excision (p. 665). — Mynter (Trans. Amer. Orthpedic Assoc, 
vol. vii.) considers the results of iodoform injections excellent, and therefore thinks 
early operation distinctly contraindicated. Excision should only be resorted to in. 



•«44 



Diseases of Children 



old and neglected cases, and in these it is impossible to remove by the usual longi- 
tudinal incisions of Oilier and Lister the fatty, degenerated, softened, and carious 
bones except in piecemeal, leaving a large amount of the tuberculous bony tissue 
and a still larger amount of the tuberculous synovial tissue in the wound. Pro- 
tracted suppuration and tuberculous relapses necessitating repeated operations, and 
possibly amputation, may follow. In order to gain free access to the diseased focus, 
Mynter, following the suggestion of Studsgaard, advocates a complete splitting of 
the hand from before backward, but he makes his longitudinal incision between 
the second and third metacarpal bones, then entering between trapezoid and os 
magnum, and between scaphoid and semilunar bones, as the hand is more evenly 
divided by this incision than by the one recommended by Studsgaard, which passes 
between the third and fourth metacarpal bones, and then opens up the joints be- 
tween os magnum and unciform bone, and between semilunar and cuneiform 
bones. Mynter operated in March, 1894, by this method. He made the dorsal 
incision reach up to the radius, but found it unnecessary on the palmar side to ex- 
tend the incision farther than the base of the thenar of the thumb. The annular 
volar ligament was, therefore, not severed. By careful 
dissection from the dorsal side, and forcible separation, 
he found it easy to avoid wounding the dorsal tendons 
and the large palmar tendinous bursa. The whole car- 
pus could now be widely opened, and it was extremely 
easy with scissors to extirpate the two halves of the 
carpus, and with a fine saw to remove the surfaces of 
the radius, ulna, and the metacarpal bones. The cavity 
was packed with iodoform gauze. The wound healed 
promptly and the result, eight weeks after the operation, 
was extremely gratifying. The patient can actively ex- 
tend and flex the wrist and move the fingers, but there is 
still some looseness of the wrist-joint, though it is 
steadily getting firmer. Mynter considers this opera- 
tion far superior to Ollier's and Lister's longitudinal, or 
the old transverse incisions, as by these last methods 
we necessarily get adhesion of the tendons to the cica- 
trix. 

Hip-joint. — In the United States all surgeons agree 
that during the acute symptoms of hip-joint disease the 
limb must be immobilized as perfectly as possible. 
Traction is applied during this time to overcome the 
reflex muscular spasm almost as invariably. After the 
pain and deformity are overcome, the practice varies somewhat. Some few rely 
on immobilization alone, using a plaster-of-Paris, spica, or a Thomas hip-splint, or 
similar device. The large majority, however, combine traction with immobiliza- 
tion, more or less complete, until all reflex muscular spasm has disappeared. After 
this the joint is still protected from pressure for months to avoid a relapse. In 
the United States, therefore, the long traction hip-splint (Davis-Taylor) (Fig. 220) 
is used almost exclusively until the convalescent stage. Then Sayre sometimes 




Fig. 220.— The Davis-Taylor 
Long Traction Hip-splint. 



Appendix 



845 



uses his short traction splint, or, like Shaffer, Taylor, and Bradford, a perineal 
crutch permitting motion at the knee and affording a modified protection from the 
traumatism of percussion. 

Where the child is large or very heavy the use of axillary crutches, in addition to 



•the hip-splint, will be advantageous in some cases, 
the hip-splint as can be borne with comfort by the 
patient. Where slight traction causes pain, this is 
-due to the tension of an abscess under the fascia lata. 

Knee-joint (p. 675). — Traction is successfully 
used also at the knee to reduce the deformity and 
relieve the pain. . It must be applied in the direc- 
tion, of the deformity, and continued as long as 
there is any reflex muscular spasm. Sayre's ex- 
tension knee-brace is, perhaps, the one best known. 
Where there is deformity New York surgeons em- 
ploy traction for a longer time than is recommended 
in England (p. 67S), before resorting to forcible 
manipulations, as many cases which will not yield 
in a few weeks will do so in a few months, and 
all traumatism will thus be avoided. Many sur- 
geons who apply traction at the hip-jcint, how- 
•ever, are content to protect the knee-joint from 
motion and percussion. 

Shaffer recommends a splint for cases of sub- 
luxation (p. 67S) unless there is ankylosis, which 
■exerts forward pressure on the head of the tibia, 
:and longitudinal traction in the line of the de- 
formity (Archives of Clinical Surgery, June, 1877). 

Goldthwaite (Bost. M. & S. Jour., Sept. 7, 
J893) describes a very admirable modification of 
^Bradford's apparatus for correcting posterior sub- 
luxation of the head of the tibia in cases where 
there is no bony ankylosis. Under anaesthesia 
the adhesions are broken up carefully by one or 
-more applications of the lever, and a protective 
splint worn afterwards until the disease is cured 



As much traction is applied by 




Fig. 221.— Bradford-Gold thwaite 
Brace for Correcting Deformity 
at the Knee. 

To apply the brace : The head of 
the tibia is forced forward as far 
as possible by the screw " b " work- 
ing in the arch "a," which raises 
the cross bar 4i c " to which the pos- 
terior band "d " is attached by the 
steel loops " e." The counter-press- 
ure is exerted by the straps ik f " 
and " g." The leg is then carefully 
straightened by the lever arm " h." 



(see Fig. 221). 

Amputation (p. 680) for tubercular disease of the knee-joint, without other 

lesions, is very rarely done here. Gibney has had but one case requiring it in the 

last five years at the Hospital for the Relief of the Ruptured and Crippled ; at the 

New York Orthopedic Hospital this operation has not been advised or done in 

that time. 

HIP DISEASE. 

Muscular Spasm (p. 693). — Involuntary reflex muscular spasm is generally con- 
sidered in America the most constant symptom of hip disease. It appears first and 
•disappears last, and is the safest guide as to the presence or absence of the disease. 



846 Diseases of Children 



c 

The writer during his observations of hip-joint disease under the tuberculin 
treatment at St. Luke's Hospital, made daily careful examinations, and came to 
the conclusion that the reflex muscular spasm was the first symptom affected by the 
injections. In the cases with more marked reaction the symptoms, although last- 
ing but a few days, exactly resembled the usual exacerbations of the disease, with 
increase of reflex spasm, less motion, or even appearance of deformity, increase of 
pain and sensitiveness, and recurrence of night cries. In less marked reactions 
several times the reflex muscular spasm became more alert, though there was no- 
rise of temperature, nor appreciable increase of joint-sensitiveness or decrease in 
motion. One case he had examined repeatedly six weeks after all pain, deformity, 
and limp had disappeared, and the reflex spasm was always detected. 

Deformity (p. 705). — Exacerbations sometimes follow rapid reduction of the 
deformity under anaesthesia. When traction is used for this purpose it must be 
applied in the line of deformity, whatever the position of the limb may be. 

Phelps ("Transactions New York State Medical Society," February, 1889) 
strongly recommends that traction be made in the line of the axis of the neck of the 
femur, not in the axis of the shaft. 

Phelps (p. 693) explains the deformities of the different stages of hip-joint 
disease as follows : The first stage is produced by voluntary effort on the part of 
the patient, aided by spasm of the muscles, in order to relieve the tension of the 
Y-ligament and capsule of the joint ; hence abduction, outward rotation, and flexion. 
Muscular spasm and a voluntary effort exaggerate the deformity of the first, pro- 
ducing that of the second stage. When flexion takes place beyond thirty degrees, 
and often with less flexion, the limb rapidly assumes the position of the third stage 
(with an occasional exception), adduction, inward rotation, and flexion, for the 
following reasons : when the limb is thus flexed the glutei muscles and the tensor 
vaginse femoris become inward rotators. The glutei cease to be abductors, and the 
external rotators are no longer rotators but abductors, with the exception of the 
quadratus femoris and obturator externus. The adductors, now being no longer 
antagonized by the great glutei muscles, cause the adduction. 

The erratic deformities he accounted for by destruction of bone changing or 
destroying leverage, burrowing of pus, dislocation, perforation of acetabulum, and: 
locking of the head of the femur in the pelvis ; possibly by the location of the 
lesion, adhesions, and irritation of special nerve-plates supplying the joint. The 
fluid tension hypothesis he thought erroneous, because many cases were unattended 
by effusion, and many cases of all the deformities seen in hip-joint disease were 
extra-capsular. 

Results (p. 701). — Sayre (New York Medical Journal, April 30, 1892) shows 
that in 407 cases treated by him without excision, the ultimate result was : 

Cure, motion perfect 71 

" " good 142 

" " limited 83 

' ' ankylosis 5 

Unknown 78 

Under treatment, 14 ; abandoned, 4 3 ; discharged, 2. Total deaths, 9. 



Appendix 



847 



As the Thomas hip-splint (p. 705) does not afford traction it is not commonly 
used in the United States. 

Excision of the Hip (p. 706). — In general there is a strong conservative feel- 
ing at present among American orthopedic surgeons on the question of hip-joint 
excision. It is considered a last resort, to be applied only in exceptional cases 
where conservative treatment cannot be carried out, or as a means of saving life. 
Bradford and Lovett express the general feeling when they say, " It must be borne 
in mind that the ultimate results after early excision are much more favorable than 
after late excision. Where a late excision is done the surgeon will always regret 
that the operation had not been done before. The results of careful conservative 
treatment, if carried out for a long time, are superior to those after excisions in a 
majority of cases, and where conservative treatment is practicable it should be pre- 
ferred. In large hospitals or among the poor and unintelligent class conservative 
treatment is sometimes impracticable, and in such cases excision is resorted to earlier 
than would otherwise be justifiable, and the results gained are more satisfactory 
than when the operation is deferred." 



SPINAL DISEASE. 

Symptoms (p. 718). — Myers has seen in several cases of high cervical disease 
severe attacks of dyspnoea and heart-failure, probably due to pressure on the cord, 
two of them ending fatally. 

Treatment (p. 720). — Recumbency is strongly advocated 
by Steele {Medical Fortnightly, February 1, 1891), who 
straps his patient to a canvas-covered iron frame and ap- 
plies head traction when the disease is in the cervical and 
upper dorsal regions (see also Bradford and Lovett, "Or- 
thopaedic Surgery," p. 54, and Sehapps, Medical Record, Sep- 
tember 9, 1893). 

Taylor's spinal-assistant brace (Fig. 222) is also largely 
used in America (p. 721) for disease in all regions. When 
the disease is above the seventh dorsal vertebra a chin-cup 
with occipital uprights is attached to the brace by means of 
a ball-and-socket joint, placed as near the occipito-atloid joint 
as possible, and the head can then be held in any position 
desired. 

Taylor (p. 721) {Medical News, No. 1,158, p. 317) has 
devised a safe, efficient, and easy method of applying a plaster- 
of-Paris jacket. The patient sits upon a bicycle saddle 
with feet resting on and fastened to rigid stirrups. The 
hands grasp handles above and a little behind the head, so 

hyptrextending the spine. Head suspension can also be „ „,,,„. 

,, , ., J , . . , , . . ■, Fig. 222.— Taylors Spin- 

added if necessary. In this way, without fatigue, without a i Brace with Chin-cup. 
motion, and with rapidity a jacket can be applied to either 

a child or a heavy adult, and the support can be carried higher up in front than is 
readily done bv the other methods. 

Lloyd (p. 725) {Annals of Surgery, October, 1892) has tabulated all published 




848 Diseases of Children 

cases of laminectomy in Pott's disease up to September, 1892. as well as several not 
previously reported. He concludes that the operation is definitely indicated in a 
certain limited class of cases. 

Gibney (p. 725) {Journal of Mental and Nervous Diseases, April, ^878), Taylor 
and Lovett (New York Medical Record, June 19, 1886), Myers (" Transactions 
American Orthopedic Association," 1S90), and Iluddleston {American Journal of 
Medical Sciences, August, 1894) have presented statistics on a large number of these 
cases, showing the frequency of recovery from the paralysis without operation. 

CLUB-FOOT. 

Shaffer (p. 729) (New York Aledical Record, May 23, 1SS5) described a condi- 
tion of modified flexion at the ankle and a contracted state of the plantar tissues 
which he called non-deforming club-foot. The symptoms were awkward gait asso- 
ciated with painful callosities at various parts of the foot ; or in more severe cases 
actual disability, pain in various parts of the foot, ankle, and leg, and even reflected 
to the lumbar region ; also tender and inflamed articular surfaces, especially at the 
junction of the first metatarsal bone with its phalanx. 

Wilson (p. 732) (" Transactions of the American Orthopedic Association. 1892 '*> 
advocates "the complete reduction of the deformity by the end of the first month 
of life, by simpler means if possible, by tenotomy otherwise. The muscular power 
of the foot should be developed as much as possible afterward." Most surgeons 
would be willing to wait longer before resorting to operation. 

It is but just to say that the surgeon meets a large class of cases which have 
been neglected for two or three years or more. These cannot be corrected by the 
simpler forms of splints, yet can be saved from operative treatment by the use of 
suitable stretching splints applied by a surgeon who knows how to use them. 

The importance of maintaining the corrected position cannot be overestimated. 
Many of these deformities will surely and slowly recur, whether they have been 
cured by operation or without it, unless exercises, massage, and attention to the 
manner of walking are kept up for a year or so. 

Phelps (p. 736) recommends the following order of operation, that one may fol- 
low the other at once if required : 1, strong manipulation ; 2, subcutaneous tenot- 
omy ; 3, open incision ; 4, linear osteotomy of the neck of the astragalus ; 5. V- 
shaped piece removed from body of os calcis ; 6, removal of cuboid and scaphoid ; 
7, Pirogoff's amputation. Exceptionally the order may be changed, so that after 
4, excision of the astragalus may be performed. 

Bradford (" Transactions of the American Orthopedic Association, 1892 ") found 
that " when the foot could not be brought straight after section of all the soft parts. 
on the inner side of the foot, the resistance was generally located in the neck of the 
os calcis, and he advocated in these cases the excision of a wedge from this bone 
just posterior to the line of cartilage " He said : In a normal foot a line drawn- 
through the middle of the sole is a straight one, but in case of club-foot after the 
removal of the astragalus the median line in front of the medio-tarsal articulation, 
formed an angle with the median line posterior to the articulation. This was due 
to the obliquity of the anterior facet of the os calcis. See also Phelps's article on 
this subject {University Medical Magazine, March, 1892). 



Appendix 



Parrish (p. 736) {Medical Journal, October 8, 1892) describes a method he has 
devised of suturing live tendons to those paralyzed, and so regaining lost function. 
He has sutured the healthy extensor pollicis tendon to the paralyzed tibialis-anticus 
tendon to remedy a case of valgus. 

Whitman (p. 740) ( New York Medical Journal, November 9 and 16, 1895) has 
devised an arched steel sole for the treatment of flat-foot which acts as a lever to throw 
the inner edge of the foot up in walking and yet is so short that it does not restrict nor- 
mal muscular action. If the foot can be replaced in proper position, if its movements 
are free and not limited by muscular spasm or inflammatory adhesions the sole can 
be applied at once, and with a proper shoe, an avoidance of faulty positions, and exer- 
cises for strengthening the weakened muscles the patient will be at once relieved. 




Fig. 223.— Whitman's Flat-foot Support. 



A. Astragalo-scaphoid joint. 
C. Ball of great toe. 



B. Calcaneo-cuboid joint. 
D. Middle of heel. 



If, however, the reduction by manipulation is impossible, the foot should be forcibly 
moved, under anaesthesia, in all directions to break up adhesions, and then forced 
into a position of extreme adduction or equino-varus and retained there in a well- 
padded plaster bandage. Although great force is sometimes used, the after symp- 
toms are usually slight, and the patient, if he desires, may walk about on the plaster 
bandage the following day. In from one to three weeks the bandages are removed 
and active treatment begun. The foot is now, though in good position, stiff, and 
all its movements are restricted and painful. It is, therefore, immersed in hot 
water, massaged, and slowly forced into a position of adduction. Voluntary exer- 
cises are then executed for twenty minutes. These are repeated several times a 
day and the surgeon once daily forces the foot into the hyper-corrected position. 
The sole is made of thin steel molded while hot on an iron cast of the foot in its 
corrected position, and is then tempered so that it is unyielding under the weight 
of the body. Fig. 223 shows the form and application of these supports. Whit- 
man calls attention particularly to the following points : 



850 



Diseases of Children 



1. That there should be an accurate adjustment of the support to the cast of the 
corrected foot : (it is never applied to a stiff and deformed foot). 

2. Lateral support is afforded as well as support from beneath, and thus is pre- 
vented the dislocation of the astragalus, the abduction and valgus, the important 
elements of so-called flat-foot. 

3. Leverage. The weak foot, properly balanced in a Waukenphast shoe, and used 
properly, will press the outer arm against the sole, and thus tighten the inner 
flange of the brace against the astragalo-scaphoid junction, where the prelimi- 
nary bulging, the first sign of flat-foot, appears. 

4. Non-interference with the functions of the foot The component parts being 
held in proper relation to one another, the foot may again become strong by 
proper exercise, the proper walk, and proper attitude, and the brace may then be 
discarded. 

Shaffer has found that in very many cases a shortening of the tendo Achillis 
precedes the appearance of flat-foot. Flexion being prevented at the ankle-joint 
occurs at the medio-tar.^al joint. He therefore advocates restoring to this tendon 
its normal length, as a necessary part of the treatment. 

A very early sign of commencing flat-foot is a rotation of 
the whole foot on an antero-posterior axis, therefore lateral 
support to the astragalus is important. As, after the bones 
have been restored to the normal positions, a cure of the de- 
formity must be maintained by increased muscular power, and 
as direct pressure weakens the muscle pressed upon, all steel 
soles and springs are theoretically objectionable. 

The treatment adopted at the Orthopedic Hospital to meet 
these indications is correction of the shortening of the tendo 
Achillis by forcible intermittent stretching, or tenotomy if 
necessary ; correction of the rotation of the whole foot on the 
antero-posterior axis by manual or mechanical force ; correc- 
tion of the abduction of the toes in the same way, and main- 
tenance of the corrected position by the use of steel ankle 
supports, riveted to the shoes, allowing free flexion and ex- 
tension at the ankle-joint and so encouraging muscular de- 
velopment, yet affording firm lateral support to the. tarsus and 
also holding the*inner side of the foot a little higher than the 
outer side, which, therefore, is made to carry most of the weight 
in walking. (See Fig. 224.) 

Torticollis (p. 741). — The Taylor spinal-assistant brace, 
with its chin-piece and occipital uprights, is well suited to 
these cases. It can be readily adjusted to any position of 
the head, and as easily re-adjusted to an improved position. 

Keen (Annals Surgery, October, 1891), Gardner (Australian Medical Journal, 
February, 1893), Powers (New York Medical Journal, 1892, p. 253), and others 
have resected the posterior branches of the upper cervical nerves with success after 
resection of the spinal accessory had failed. 

Genu Recurvatum (p. 750). — Myers, in examining a considerable number of 




Fig. 224. — Shaffer's 
Flat-foot Support. 
1. Astragalo-scaphoid 
pad. 2. Inner side of 
sole piece raised high- 
er than outer side, 3. 



Appendix 851 

cases of genu recurvatum, found that the patellae generally develop later on, though 
they may not be found at birth. 

Arrest of Development (746). — Hasse and Dehner (Arch. f. Anat. u. Physiol. 
Abtheil., 1893) have found that in the majority of cases the lower limbs are of un- 
equal length, that asymmetry is the rule and not the exception. 

Club-hand (p. 747)- — R. H. Sayre (New York Medical Journal, November 4, 
1893) operated upon an aggravated case in which the radius and thumb were 
absent, as well as the first metacarpal bone and a certain number of the carpal 
bones. The marked curve in the ulna was first corrected by osteotomy. After 
union in a straight line was secured, and after several weeks of stretching the con- 
tracted tissues had failed, the styloid process of the ulna was cut off, the os magnum 
and unciform removed, and the end of the ulna put into the gap in the carpus thus 
formed. The hand is now approximately in line with the forearm. There is free 
motion at the wrist, and the ability to grasp objects is greater than it was before 
the operation, though extension of the hand is poor. 

Congenital Dislocation of the Hip (p. 751). — Gibney (Annals Surgery, 
December, 1894) says that the results he has obtained in his cases of congenital 
dislocation of the hip from Hoffa's operation have been far from satisfactory. He 
reports on six cases. He attributed his ill success to some fault of technique, 
since suppuration followed the operation in the majority of cases. The age also 
of his patients was too far advanced in most of the cases. 

Bradford (Annals Surgery, xx., No. 2, p. 129) found that contraction of the 
anterior fibres of the capsule may sometimes prevent reduction. 

Paci (Arch, di Ortop., Ann. ix., No. 6, and Ann. x., No. 1) reports on fifteen 
cases treated by his method, and the results are almost perfect a year or more after 
operation. His method is to forcibly manipulate the limb, as if to reduce a 
traumatic dislocation — that is, the limb is first forcibly flexed as far as possible, 
then abducted, then rotated outward, then extended. Afterwards the thigh is held 
completely extended and immobilized, and traction applied. If the shortening is 
not completely overcome at the first operation, a subsequent one will probably 
accomplish the reduction. In about two months the plaster-of-Paris splint is 
removed and an extension apparatus applied. Four months after the operation 
the patient is allowed to get up and walk with crutches. At night the extension 
is reapplied. The limb is massaged twice daily, and once a day receives electrical 
treatment. 

Schede's recently recorded cures of this condition by conservative treatment 
seem to indicate that a persistent attempt should be made to cure without resort- 
ing to the open operations of Hoffa and Lorenz, if this is practicable. The results 
from operation should improve with improved technique and more careful after- 
treatment. Myers (Annals Surgery, December, 1894) found the mortality in one 
hundred r;nd seventy-three recorded cases three and three-tenths per cent. 



852 Diseases of Children 



MILK. 

A superstitious belief in the superior virtues of the milk of "one cow'' is still 
common among the public, and it is often looked upon as a most important matter 
to secure this. As a matter of fact, a good average milk is more likely to be 
obtained from mixing the milk of a nutnber of cows than in taking it from one, for 
it is well known that the first portion of milk obtained from the udder is poor in 
fat, while the last portions are rich, the amount varying from two to eight per cent. 
If the first part of the milk taken is reserved for the infant, it is tolerably certain 
to get a poor milk. Whenever a cow is specially reserved to supply milk for an 
infant, care should be taken to see that it is not an old one, and the last portions 
of milk should be taken for the child. 

What is of far more importance than the question of " one cow" is the question 
as to how the cows are fed, and the care taken to prevent the contamination of the 
milk with organic matters. In the vicinity of our large towns it is no uncommon 
thing to see cows out at pasture in fields watered by brooks contaminated with 
sewage, of which they freely drink ; moreover, they are extremely likely to lie 
down in the sewage water, and their udders, and consequently the milker's hands, 
become befouled with sewage. In the winter time the cows are frequently fed 
largely on turnips and brewer's grains, instead of hay, maize, or other dry fodder ; 
possibly also their sheds are infrequently cleaned out and only sparingly supplied 
with straw, so that the animals lie in faeces and their udders may be seen caked 
with dried excrement. It is no uncommon thing to find a greenish-looking sedi- 
ment in milk from second-rate dairies, due to contamination of faecal matters. The 
storage of milk is an exceedingly important matter, for milk readily absorbs gases, 
and is readily contaminated when kept in cellars or kitchens pervaded with sewer- 
gas or the emanations of decomposing animal substances. The temperature at 
which it is kept is also important, as it far more quickly turns sour and decomposes 
when kept in a warm place than in a cool place. This is recognized by many milk 
purveyors, who at once take measures to cool the milk directly it is received fron 
the cow. According to Soxhlet fresh milk turns sour and curdles at the following 
temperatures and times : 

At 32 C. (90 F.) in 19 hours. 
At 25 C. (77° F.) in 29 hours. 
At 17!° C. (63. 5 F.) in 63 hours. 
At io° C. (40 F.) in 208 hours. 
At o° C. (32 F.) in 3 weeks. 

BARLEY WATER. 

Place a tablespoonful of best pearl barley in an enamelled saucepan, add a pint 
of water, and boil for a few minutes, stirring all the time so as thoroughly to cleanse 
the grain. Pour the water off the barley, replace by a pint and a half of clean 
water, and simmer gently for an hour, and strain. Another and better method is 



Appendix 8 



03 



to use barley meal prepared from the whole grain, inasmuch as the greater part of 
the gluten is found in the cells lining the husk (Jacobi). The grain should be well 
washed and ground in a coffee-mill kept for the purpose. The barley water used 
during the early months of infancy should be a thin mucilaginous fluid ; in the later 
months it should be thicker, or barley jelly may be used to thicken the milk 

OATMEAL WATER. 

A table-spoonful of coarsely-ground oatmeal should be placed in a pint of water ; 
simmer gently for an hour, replace the water evaporated. 



ARROWROOT WATER. 

Take two tea-spoonfuls of best arrowroot and a pint of water j simmer for five 
minutes, stirring constantly. 

WHEY. 

Warm a pint of milk to blood-heat ; add a tea-spoonful of ' artificial rennet ;' in. 
a few minutes the curd will have separated from the whey ; break up the curd with 
a fork and allow it to stand till the curd has subsided ; decant and boil the whey. 
Whey thus prepared may be given to a newly-born infant, cream or milk being 
added according to its powers of digestion. Whey with some added brandy is use- 
ful as a substitute for 'white wine whey,' and generally agrees better. 

VEAL TEA. 

Take one pound of veal free from fat and bone, cut into small pieces the size of 
dice, place in a covered jar with a pint and a half of water or barley water, cold ;. 
place in an oven not too hot, and bake for three or four hours — or it may be left in 
the oven all night ; strain and remove fat. 



SCRAPED MEAT. 

Take a thick rumpsteak of the best quality ; scrape it with a knife until reduced 
to shreds. A sandwich can be made by placing a small portion between very thin 
slices of bread and butter. Some children will take the meat pulp out of a tea- 
spoon or mixed with gravy or beef-tea. Scraped meat can also be prepared from 
rumpsteak which has been frizzled for a few moments on a quick fire, the burnt 
outside being cut off before being scraped. 

RAW MEAT JUICE. 

Finely mince a pound of the best rumpsteak freed from fat. Place in an earthen 
vessel with sufficient cold water to well cover it, add some lump sugar, and let it 
stand for four hours. Strain through muslin. It can be given with port wine if 
thought desirable. 



854 Diseases of Children 



LINSEED MEAL POULTICE. 

Warm a basin, pour in boiling water ; sprinkle in the meal, stirring vigorously, 
till it becomes of the consistency of thick porridge ; spread on tow or old linen, 
turning in the edges all round ; before applying put it against one's cheek to feel 
that it is not too hot. Retain in position with a broad flannel roller, secured with 
safety-pins. Renew every four hours or oftener. The poultice should not exceed 
half an inch in thickness. Caution is necessary in poulticing the chests of infants, 
in order not to overload the chest and tire out the respiratory muscles. 

MUSTARD POULTICES. 

These may be made in a similar way to the above, the mustard being mixed 
with warm water, and stirred well into the linseed poultice. One part of mustard 
to three or four of linseed meal may be used for infants and young children, kept on 
for four hours, and repeated according to the amount of redness produced. 

BRAN POULTICES. 

Bran poultices are preferable to linseed poultices when the weight of the latter 
is an objection, as in colic. A flannel bag is filled with bran, boiling water is then 
poured over it till it is thoroughly saturated ; it is then wrung dry in a towel, placed 
against one's cheek to test the temperature, and applied. 

HOT FOMENTATIONS. 

Flannel or spongio-piline may be used, being wrung out of boiling water in a 
towel, sprinkled with laudanum or turpentine according to the effect desired, and 
.applied. The fomentations should be retained in position by means of a flannel 
bandage. 

ANTIPYRETIC METHODS. 

Sponging. — The readiest means of reducing temperature when the fever is 
moderate in degree is by sponging. The child should be stripped and lie upon a 
blanket or sheet with a waterproof beneath ; a large sponge should be used, and the 
face, trunk, and extremities sponged for live or ten minutes. The water used 
should be cold, but with nervous patients it is well to begin with tepid water. If 
the child is feeble it may have a hot bottle to its feet during the sponging. Cold 
sponging is a useful and safe means of reducing temperature in all febrile conditions, 
but its action is only temporary. 

Packs. — The efficacy of a continuous, pack in reducing temperature depends 
upon its action on the skin in producing sweating, the cooling effect of the applica- 
tion of the wetted sheet being temporary only, unless frequently reapplied. Packs 
are most useful in conjunction with certain drugs, as aconite and quinine. To 
apply a cold pack a sheet should be wrung out of cold water and applied to the 
patient from the neck to the feet ; a blanket is then wrapped around the sheet. It 



Appendix 855 

should be reapplied in a quarter of an hour if the temperature appears high, but 
frequently the patient goes to sleep in the pack, and it may be wise to leave him. 
undisturbed, for an hour at least. Cold packs are often of great service in scarlet 
fever, measles, and other febrile conditions. In pneumonia packs are often useful, 
the wet sheet being applied only round the chest. 

Baths. — The cold or graduated bath is the most rapid means of reducing a high 
temperature, and has the advantage of being readily applied. The child may be 
placed in a bath of ioo° F. and the temperature of the bath reduced by the gradual 
addition of cold water. The cold water may be poured over the patient's head if 
the temperature is high. Cold baths may be used in enteric, pneumonia, measles, 
indeed in a high temperature from any cause excepting scarlet fever or diphtheria. 
In severe attacks of these diseases the cold bath is apt to depress too much, the 
patient becoming cold and collapsed. 

Enema. — Enemata of cold water have been successfully used in reducing tem- 
perature, but can only be of limited application. 

Ice-bags. — Ice applied to the head or chest in a rubber bag, or flannel wrung 
out of ice and water, form effectual means of reducing temperature. 

Aconite. — Given in the form of tincture, is useful as an antipyretic in conjunc- 
tion with packs. It is necessarily of limited application on account of the depres- 
sion it produces if pushed. A quarter to one minim may be given every hour in 
pneumonia, the effect being carefully watched. 

Quinine. — Quinine may be given to reduce temperature in doses of two to ten 
grains of the sulphate in syrup of orange-peel, milk, or cocoa ; it is useful for this pur- 
pose in conjunction with packs in malaria, scarlet fever, pneumonia, and measles. 
If given by the rectum, the neutral bisulphate should be used, or the sulphate 
should be dissolved with the least possible excess of acid. It is well to bear in mind 
that it is useless to expect absorption from a rectum loaded with fasces, and a 
drachm of glycerine must be administered in order to relieve the bowels before in- 
jecting the quinine. The quantity given by rectum must be double that given by 
mouth. 

The subcutaneous injection of quinine is not often resorted to in infants, inas- 
much as a neutral solution is not often at hand when wanted. In a high tempera- 
ture due to malaria it would be of service. 

Antifebrin.— This drug is much used at the present time in reducing high 
temperatures. It maybe given in the form of powder ; or in wine, as it is insolu- 
ble in water. It is better to begin with a small dose and to repeat every three or 
four hours if necessary. One-grain doses may be given under two years of age, two 
grains from two to four year? of age, three to four grains for older children, and 
repeated if necessary every four hours. An overdose is apt to produce cyanosis, 
weak pulse, and profuse sweating. This drug is useful in acute pneumonia, measles, 
typhoid, and scarlet fever. The continuous use of it should be avoided if there are 
any symptoms of cardiac failure ; toxic symptoms, especially jaundice and albumi- 
nuria, may arise. 

Antipyrine. — This drug is used in a similar way to antifebrin ; the dose given 
must be twice as large to produce the same effect. 

Phenacetin is another drug of the same series, and may be given in doses of the 



856 Diseases of C/iildren 

same size as antifebrin. This is much preferred in the United States to other 
drugs of its class, as being safe and equally effective. 

HOT PACKS. 

Hot packing is most useful in nephritis, especially when the kidneys are choked. 
A blanket is wrung out of hot water as dry as possible and quickly applied, care 
being taken that it is not too hot ; it may be renewed in half an hour. 

HOT AIR OR VAPOUR BATHS. 

These are useful under similar circumstances to the hot pack ; they are best ap- 
plied by means of a special apparatus, Allen's being the best. A hot vapor bath 
can be improvised for a child with a 'bronchitis kettle,' or even an ordinary ket- 
tle, and spirit or paraffin lamp, a chair being used as a 'cradle.' There is, how- 
ever, some risk of accident. 

MUSTARD BATH. 

An ounce of mustard to a gallon of water (ioo° F.) is the right proportion. The 
mustard should be made into a paste in a basin, and gradually stirred into the 
water of the bath. Useful in diarrhoea, pneumonia, or collapse from any cause ; 
more especially in infants and young children. 

NARCOTICS. 

Opiates. — Infants are sensitive to the action of opium, and this drug requires 
to be administered with great caution and its effect carefully watched. At the same 
time there cannot be a doubt as to its value in many instances, particularly in reliev 
ing pain and quieting the overaction of the bowels. In prescribing it to infants, 
not only the question of age, but also the size of the child, and the complaint from 
which it is suffering, and the degree of exhaustion present, must be borne in mind. 
It is obvious that the dose of opium suitable for a strong, well-nourished infant of 
six months of age, suffering from colic, might be unsafe if given to an infant of 
eighteen months in the last stages of gastro-intestinal atrophy. Infants in the last 
stages of diarrhoea, atrophy, and pneumonia are exceedingly sensitive to opium, 
and caution should be observed in giving it to them. Moreover, such infants pass 
sometimes into a comatose state before death, not unlike the condition produced 
by opium poisoning, and under these circumstances the immediate cause of death 
might be attributed to opium. As a general rule, and presuming the infant is a 
well-nourished one, I grain of Dover's powder may be given to an infant of six 
months and repeated in four hours if necessary. Larger doses may be given with 
safety if the infant can be watched, and indeed, if the infant is suffering from acute 
colic or intussusception, twice or even four times the dose named may be given. 
In one case coming under our observation, -}$ grain of acetate of morphia was given 
to a strong infant four months of age suffering from acute abdominal pain ; the 
infant became drowsy, the pupils were semi-contracted, it remained in a semi- 
■comatose state with sighing respiration for two or three hours, when it woke up 



Appendix 857 

perfectly well. It was evident, however, that the limit of safety had been passed. 
Three grains of pulv. kino co. (Br.) were given to an infant of six months, who was 
much wasted and suffering from diarrhoea, at intervals of four hours, three doses 
being given in all. The second dose made it drowsy ; it died a few hours after the 
third dose, with all the symptoms of opium poisoning. It had taken in all nearly 
\ grain of opium. One grain of Dover's powder, or a minim (=tott g rain ) °f U( h 
morphia, is an average dose for on infant a year old, and may be repeated in two 
or four hours if necessary. Two or three grains of Dover's powder, or two or three 
minims of liq. morphinse, may be given to children between two and four years of 
age. Children over six years of age are much less sensitive to opium than younger 
children, and J to \ grain of opium may be given if necessary to relieve pain in 
peritonitis or other diseases. It must be borne in mind that idiosyncrasies may be 
met with, and infants may be found exceedingly sensitive to opium, or, on the 
other hand, very tolerant. 

Subcutaneous injections of morphia are best avoided in infants under a year, and 
are not often required for young children ; ~ 5 l j grain would be a full dose for an 
infant of a year. 

Codeine is of some value in relieving pain in children, especially in connection 
with the alimentary system. It may be given in syrup of orange. It may be given 
in doses of -^-^ grain to infants and young children, and \-% grain to older chil- 
dren. It is useful in colic, diarrhoea with tenesmus, and irritative cough — in the 
latter perhaps not so good as morphia. 

Chloral hydrate.— Chloral is soluble in water, and maybe given 2 or 2$ grains 
to the drachm of cinnamon water, sweetened with syrup of orange. Infants and 
•children tolerate chloral well ; its principal use, combined with bromide, is in 
convulsions and to procure sleep. It is of but little use in relieving pain. 2^-5 
grains may be given to children from a year to two years old. 5-10 grains may be 
given to older children. Very much larger doses have been given to procure an- 
aesthesia (Bouchut). 

Bromide of potassium. — 2-24 grains to the drachm of water sweetened with 
syrup of orange or lemon, and spirit of chloroform. The liquid extract of liquor- 
ice hides the taste fairly well. 3-5 grains may be given to children from a few 
weeks to two years of age, and repeated every two hours if necessary. 20-60 grains 
a day may be given to older children who are suffering from cerebral excitement or 
fits. There is little risk in an overdose ; children well under the influence of bro- 
mide are lethargic, speak with a slow drawling tone, and suffer from acne. 

Antipyrine acts as a sedative in small doses in infants and young children ; 
^-l grain may be given to infants suffering from colic or painful dentition. 

Belladonna and atropine are much used in whooping-cough, incontinence of 
urine, and as external applications. Children are tolerant of these drugs, and 
larger. proportional doses than those given to adults may be prescribed, if they are 
carefully watched. Children of one to two years of age may be given 1-3 drops of 
the tincture every four hours. Older children, 2-7 minims or more, though it is 
wiser to begin with minimum doses and gradually increase the dose. Atropine is 
more dangerous, and is best avoided in young children. Children five years old 
and upward may be given minim doses (-p^o grain) of the liquor, cautiously in- 



858 Diseases of Children 

creased. Temporary excitement and dilated pupils are the result of an over- 
dose. 

Cannabis indica. — Children bear this drug well ; it is usefully added to bromide 
in 2\ minim to 10 minim doses of the tincture in whooping-cough. 

Hyoscyamus. — Tincture of hyoscyamus is used as an anodyne in place of 
opium. Its nauseous taste is one objection to it ; it may be given in 5-minim doses 
to an infant a year old, 10-30 minims to older children. 

Hyoscyamine sulphate is frequently substituted for the tincture, but, like 
atropine, it must be used cautiously, or not given at all to infants. yuT7 g r > cau " 
tiously increased to -§\ r gr. , may be given to older children ; larger doses have been 
given. 

Hyoscine may be given with caution in the same doses as above, but is said to 
be more active. 

PURGATIVES AND LAXATIVES. 

Mercury and chalk by itself, or in combination with rhubarb and soda, is 
very frequently given as a laxative for infants a few months old, or when the stools 
indicate some irritative matters in the bowels. For this purpose \-2 grs. may be 
given twice a day for a few days, or for two or three successive nights. 

Calomel is preferable for older children on account of the smaller dose required; 
it may be given with soda, euonymin, rhubarb, scammony, or jalapine. A grain 
may be given with white sugar to a child of one to three years, half a grain to an 
infant of six months, as a purgative. Half the quantity may be given with other 
drugs ; thus — calomel, gr. \ ; scammony resin, gr. \ ; calomel, gr. \ ; pulv. rhei, gr. 
\ ; sodse bicarb., gr. ^ ; calomel, gr. \; euonymin, gr. \. Small pilules made of 
calomel, gr. \ ; ex. colocynth. co., gr. £ ; calomel, gr. £ ; ex. rhei, gr. f, answer very- 
well. Some prefer to give small doses of this drug, as gr. £, repeated every hour 
till the bowels act. 

Rhubarb forms a safe and non-irritative purgative, and is especially useful in 
combination with soda when a laxative and stomachic is required. It unfortunately 
has a nauseous taste, best covered by syrup of orange or spirits of nutmeg. Tab- 
loids of rheum c. soda are very convenient. 

The syrup is a good preparation, especially in combination with an equal quan- 
tity of syrup of senna, of which half a tea-spoonful to a spoonful is a dose. ' Mist, 
rhei co.' is much used as a laxative, given two or three times a day, especially in 
infants when the stools are 'putty-like ' and sour-smelling ; thus, syrup, rhei, TT^xx ; 
sodee bicarb., gr. j; aq. menth. pip., 3 j- 

Inf. rhei with sodge carb. and sp. amnion, aromat. forms a useful carminative 
for infants — such as sp. amnion, aromat., 7T]jii ; sodae bicarb., gr. ii ; syrup, zingib., 
7T\_xx ; inf. rhei ad 3j; sp. amnion, aromat., Tf^iiss ; syrup, zingib. T^xx ; inf. 
rhei, Tij^xv ; inf. gent. co. ad 3 j. 

Aloes. — Much used for constipation, either in the form of the aq. ext. or aloin 
in pilules. Small pilules containing -J grain of aq. ext. of aloes are readily swal- 
lowed by children, or they can be divided with a knife and given in jam. Aloin is 
useful in treating the constipation of infants and young children ; ' anticonstipa- 
tion' 'tabloids,' containing aloin, gr. -§-, belladonna ext., gr. |, strychnine, gr. -/j, 



Appendix 859 

ipecac, gr. -, 1 ,,-, may be used, half a one being given to infants once or twice a day, 
mixed with a little white sugar. 

Senna. — Mostly given in the form of the compound liquorice powder, syrup, or 
infusion. The former is much used as a household medicine, quarter to one tea- 
spoonfuls being given mixed with a little water. The syrup is pleasanter to take, be- 
ing free from any grittiness ; a tea-spoonful is the usual dose ; it is most effective 
when given with an equal quantity of syrup of rhubarb. The infusion is given in 
constipation with some bitter, as strychnine or calumba, such as liq. strychnia?, 
TT^ss ; glycerine, TT^x ; inf. sennae, TT^xx ; inf. calumbse, ad 3 j, b. or t. d. s. Old 
preparations of senna are apt to gripe. 

Cascara sagrada is of much value in habitual constipation in infants and chil- 
dren. It may be given in syrup or some of the elixirs, chocolate bonbons or loz- 
enges. Some chemists prepare an extract from which the bitter principle has been 
removed. Five to 20 minims of the liquid extract once a day is the usual dose. 

Podophyllum resin may be given in powder or 'tabloid ' form to infants and 
children suffering from constipation, beginning with -gV gr. to -^ gr. two or three 
times a day. Liq. podophylli (gr. £ ad 3 j), made by some chemists, is a useful 
preparation, and may be prescribed with strychnine, bitters, acids, or alkalies. 

Rubinat, Hunyadi Janos, Carlsbad mineral waters — a table-spoonful or 
more in warm water or milk, given before breakfast — are very useful purgatives for 
children over four years of age. 

EMETICS. 

Pulv. ipecac, is the best and safest emetic for children. It may be kept in 
the form of powder or the 5 grain ' tabloids.' Five grains may be given, and re- 
peated every ten minutes till vomiting is produced, to infants and young children. 
Ten grains may be given in one dose to older children, and repeated in ten minutes 
or a quarter of an hour. There is great difference in children with regard to the ease 
with which they are made to vomit. In the later stages of croup or pneumonia, 
when the face and lips are pale or bluish, it is difficult to excite vomiting ; indeed 
at this stage emetics are useless. 

Apomorphia is apt to depress too much ; it may be given -jq-y-u g r « subcutane- 
ously, but not to infants. 

Alum. — Half a tea-spoonful in honey or syrup is useful in whooping cough. 

EXPECTORANTS AND DIAPHORETICS. 

Ipecacuanha is usually given in the form of vinum ipecac, in doses of Tf\_iiss— 
Tf^v to infants up to a year old, ITtv-'u\xv to older children, repeated every two to 
four hours. It may be given with TT[v-x of aq. laurocerasi and TTj,x of glycerine to 
the drachm of water ; or syrup pruni virgin, may be added. Vin ipecac, is apt to 
lose its strength by keeping. 

Pulv. ipecac, co. is a useful expectorant (see Opium). 

Antimony. — Mostly given as vinum, in the same doses as vin. ipecac; often 
prescribed with mist, amygdalae. Both ipecac, and antimony are better given in 
small doses, frequently repeated, than in increasing doses. In acute bronchitis or 
laryngitis it is often useful to push either ipecac, or antimony freely till sickness is 



86o Diseases of Children 

produced, then to lessen the dose. Both these drugs are given in the early stage 
of bronchitis when rhonchi and sibilus are heard. 

Emetine. — Dose too— Aj gi".; riot often prescribed. 

Liq. ammon. citratis or liq. ammon. acet. is of ten combined withvin. ipecac, 
or vin. antimon. in doses of TTlxv-TT^xx for infants up to a year, 3 ss to 3 j for 
older children, well diluted, with syrup tolu, aurant., or pruni virgin, to cover 
the taste. 

Sp. ammon. aromat. — Dose Tf^ii-Tf[iii in a drachm of syrup or glycerine and 
water for infants ; TT^iv-Tf^x, well diluted, for older children. 

Ammon. carbonat. or chloride. Dose : gr. iss-gr. v, well diluted, and dis- 
guised as far as possible by syrup aurant., tolu, or scillae. 

Squills. — Useful as a stimulating expectorant in bronchitis, when the secretion 
is free, fluid rales being heard in the chest, and but little being coughed up. Tinc- 
ture : doses mii— TT^iii for an infant up to a year old ; TT^iii— TT^v for older children, 
repeated every four hours. Syrup or oxy-mel : TT^x- 3 ss. The syrup is often com- 
bined with ipecac, or ammonia, according to the stage of the bronchial affection. 

Terebene. — Often useful as a stimulating expectorant ; not often given inter- 
nally to infants. TT[ii to TI^v may be given on sugar to older children, or suspended 
in mucilage and syrup of lemon. 

ANTACIDS AND CARMINATIVES. 

Alkalies and aromatics are frequently required in the dyspepsias of infancy. Of 
the former, sodas bicarb, gr. iiss, magnesias carb. gr. iii, combined with syrup 
zingib. and aq. anisi ad 3 j, is useful ; or sodas bicarb, gr. iiss, tr. nucis vomicae, 
TT^, tr. cardamom, co. TT^v, sp. chloroformi, TT^iiss, aq. anethi, ad 3 j, given occa- 
sionally. 

TONICS. 

Cod-liver oil takes the first place. It is best given after meals and in the form 
of an emulsion ; some of the latter are to be obtained combined with lime salts. 
71\x to IT^ xx of the oil twice or three times a day is the dose for infants ; 3 ss to 
3 j may be given to older children. Dyspepsia, catarrh of intestines, and diarrhoea 
should be treated before cod-liver is given. Inunctions of warm cod-liver are often 
useful ; the oil is applied on a sponge and the child clothed in a flannel nightdress. 

Acids. — Dilute nitric acid (TT^iss to TT^ii, aq. ad 3 j) is often of much service dur- 
ing convalescence. It may be combined with tr. cinchonas co., or decoc. cinchonas 
and syrup limonis. 

Iron. — Often given as vinum ferri, TT^x to 3 j, syrup ferri phos. co. IT^x to 3 j, or 
tr. ferri perchlorid. Tf^i to TT^ii, in a wineglass of water at meal times. Ferri et 
ammon. cit. may be combined with alkalies and mix vomica. 

STIMULANTS. 

Alcohol necessarily takes the first place in the list, and is beyond all question 
of value in treating acute disease when there is evidence of a flagging heart. It is 
not a matter of much importance what form of alcohol is selected, presuming it is 



Appendix 86 1 

of good quality. Brandy, in the form of mist. sp. vini gallici, *is the one perhaps 
most generally useful. In hospital whiskey frequently takes the place of brandy 
for the sake of economy. Curacoa, champagne, port wine, more or less diluted 
according to circumstances, may be used. Alcoholic stimulants are called for in 
the adynamic forms of scarlet fever, diphtheria, broncho-pneumonia, acute diar- 
rhoea, and other allied conditions. The pulse is the best guide : a feeble, irregular, 
intermittent pulse calls for alcohol, mere rapidity of pulse does not. Drowsiness, if 
it does not contra-indicate alcohol at least calls for caution in its administration, 
as overdosing with alcohol is apt to make the drowsiness more pronounced, espe- 
cially that form due to a hypervenous condition of blood. Delirium is often made 
worse by alcohol, especially if there is evidence of cerebral congestion, the con- 
junctival vessels being injected as in the early days of scarlet fever. In such cases 
opium or bromide answers better. Vomiting is a signal for discontinuing alcohol, 
for a while at least. Unfortunately champagne, so useful as a rapidly diffusable 
stimulant, is apt to produce sickness. The amount of alcohol given necessarily 
depends upon circumstances : drachm doses of brandy, or even more, every hour, 
may be given in some cases of scarlet fever or broncho-pneumonia, with advantage 
even to young children. In infants alcohol is principally of value in colic and acute 
diarrhoea, and may be given well diluted with barley water, arrowroot, or milk. 
Port wine sometimes seems to agree better than spirit. In chronic disease alcohol 
is of less value than in acute, as the long-continued administration of it certainly 
has its evils, and is apt to produce dyspepsia and sluggish liver. In anaemia, scro- 
fulosis, and tuberculosis the wine of St. Raphael, port wine, or porter may some- 
times be given with advantage. [Also see Heart-stimulant, under Pneumonia, p. 
374] 

FORCED FEEDING. GAVAGE. 

Difficulties sometimes arise in feeding immature infants and those with cleft 
palates, the infant being too weak to suck ; or the conformation of the mouth may 
render this impossible. In diphtheria, when the tonsils are enlarged and painful, 
or in paralysis of the pharynx, ' forced feeding ' may have to be resorted to. For 
weakly infants the ' fountain ' feeding bottles have been devised, and the ' bibe- 
rons pompes ' of the French ; there is, however, no difficulty in feeding a weakly 
infant by means of the ordinary boat-shaped feeder if held slightly inclined. In- 
fants with cleft palates have to be fed by spoon or by means of the ' Scott-Battams 
method,' namely, a piece of india-tubing attached to a glass syringe. In difficulty 
of swallowing from any cause this last method is the most generally useful. An 
ordinary glass syringe is taken and filled with milk, beef -tea, or other liquid nour- 
ishment, a piece of india-rubber tubing a few inches long is attached, the latter is 
passed into the mouth to the back of the tongue, and the piston of the syringe slowly 
pressed from time to time, so that small quantities of fluid are swallowed from time 
to time. The tube need not be passed between the teeth ; if the latter are clenched 
the tube may be passed between the cheek and the jaws. In cases where the pha- 
rynx is completely paralysed a medium-sized india-rubber catheter must be passed 
through the nose into the pharynx and oesophagus, and food introduced into the 
stomach. 



862 Diseases of Children 

Forced feeding has also been used by Dr. Kerley, of New York, in cases of per- 
sistent vomiting in young infants, his experience being that food introduced 
directly into the stomach by a tube and funnel is less readily rejected than if 
swallowed in the ordinary way. His method is as follows : The infant is held in a 
half reclining posture on the nurse's right arm ; a soft india-rubber catheter, at- 
tached to a funnel of three or four ounces capacity by a rubber tube two and a half 
feet long, is rapidly introduced into the stomach, a half to two and a half ounces 
of liquid food introduced into the funnel ; the latter is then raised and when empty 
rapidly withdrawn. This method of forced feeding appears to be more successful 
in infants than in older children. A preliminary stomach washing should precede 
the first forced feeding. 

STOMACH WASHING. 

Washing out the stomach is often a highly beneficial proceeding in the dyspep- 
sias of infants, especially when vomiting of decomposing curd is a prominent symp- 
tom. The removal of curd which may have remained in the stomach for some days, 
as well as the acid mucus, is certain to be beneficial. The method of carrying it is 
the same in infants as in adults. An india-rubber catheter as large as possible is 
passed down the pharynx into the stomach, and connected by means of an india- 
rubber tube, two or three feet in length, with a funnel. One or two ounces of 
warm two per cent, solution of borax is introduced into the tunnel ; the latter is 
raised so that the fluid flows into the stomach, and then lowered and inverted so as 
to allow of the return of the fluid contents of the stomach. This proceeding is 
repeated till the returning fluid is clean and sweet. Curdy material often escapes 
by the side of the tube. 

Stomach washing is useful not only in the chronic dyspepsias of infancy, but 
also in the vomiting of acute gastric catarrh and other forms of vomiting. 

ENEMATA. 

Enemata are required for various purposes during infancy and childhood. A 
simple enema may be required to unload the bowels and clear away scybala which 
have collected in the large bowel ; or they may be given for other purposes, such 
as that of applying local treatment to the mucous membrane of the colon, to re- 
place an invagination, or to destroy oxyurides which are present there. ''Rectal in- 
jections are also resorted to as a means of administering drugs or nutriment. 

Purgative enemata are generally given with a fountain syringe, and at a temper- 
ature of about ico°. They may consist of soap and water with the addition of 
olive oil, castor oil, or turpentine. When the latter is used a teaspoonful of ol. 
terebinth., two teaspoonfuls of olive oil, and the yolk of an egg may be shaken up 
with four or five ounces of water for a child of two or three years. A large quan- 
tity of fluid may be injected if the fluid is required to reach the upper part of the 
large bowel. Some care is required, in giving an injection, to do it slowly, avoid- 
ing all force. If it is required simply to unload the lower bowel, an injection of a 
teaspoonful of glycerine is all that is required. Enemata for the destruction of the 
oxyurides are best given after a sharp purgative has been administered, in order to 



Appendix 863 

drive the parasites as much as possible into the lower part of the intestines. For 
this purpose the turpentine injection referred to above answers very well, or half a 
pint to a pint of corrosive chloride of mercury (i to 2,000) may be used. Re- 
peated ' irrigation ' of the large bowel has been much practised on the Continent 
{Monti, Baginsky) in various diseased conditions, such as constipation, dysenteric 
diarrhoea, catarrh of the large bowel, &c. Large quantities of water or various 
solutions are injected by means of an india-rubber tube- with a nozzle to fit in the 
rectum, and a funnel. The forcing of a large quantity of fluid into the colon, es- 
pecially in young children, is not always easy, on account of the straining and 
struggling which it is apt to produce, and forcible injection of fluid by means of 
raising the funnel with tube attached is not free from danger. In irritable condi- 
tions of the colon warm mucilaginous fluids, such as decoction of arrowroot, two 
to four ounces, with two to five minims of laudanum, is soothing, and relieves tenes- 
mus. The subnitrate of oxide of bismuth, suspended in mucilage, and three or 
four ounces injected, is also useful. In more chronic cases, alum, zinc, sulphate, or 
nitrate of silver may be used. On the whole, opiates are the most comforting to 
the patient. 

Nutrient enemata may be given of peptonised beef-tea, or milk with brandy, or 
some other form of alcohol. 

DIRECTIONS FOR USE OF DISINFECTANTS. 

Solution A. — Chloride of lime, eight ounces ; soft water, one gallon. 

Solution B. — Liq. sodse chlorinatse, one part; soft water, five parts. 

Solution C. — Corrosive chloride of mercury, four ounces ; permanganate of 
potash, one dram; soft water, one gallon. 

Stock bottles to be kept locked up, and labelled ' POISON.' 

For use : — one fluid ounce to be mixed with one gallon of water. 

Use of A. — For the disinfection of excreta : Mix well with each stool half a 
pint of solution A, and allow it to stand for ten minutes before emptying it into the 
closet. Treat the vomit of fever patients similarly, and keep the sputa-cups of 
phthisical patients half full of the same solution. 

Use of B. — (1) For the washing of hands and the cleansing of spatulas, ther- 
mometers, and other infected instruments ; (2) for the thermometers to be kept in ; 
(3) for the sponging of those dying of fever, previous to their removal to the mor- 
tuary ; (4) diluted with four times its bulk of water, for the daily sponging of fever 
patients. 

Use of C. — For the disinfection of clothes : The clothes to be soaked in the 
solution for two hours, in an earthenware vessel, before being sent to the wash. 

To Disinfect a Room. — Tightly close all windows, fire-places, and ventila- 
tors. Moisten powdered sulphur with spirit, place it in a shallow iron pan sup- 
ported on a couple of bricks in a bowl of water ; light it, and keep the room closed 
for ten hours. Three pounds of sulphur must be used for each 1,000 cubic feet of 
air space. N.B. — 5 lbs. is necessary for each special ward. Then open all win- 
dows, &c, and wash the floors, walls, furniture, &c, with the following solution : 
Solution C, four fluid ounces ; water one gallon, taking especial care to thoroughly 



86 4 



Diseases of Children 



wash out all dust from window-ledges, corners, &c. Allow free ventilation for 
twenty-four hours. 

LOEFFLER'S D-BACILLUS. 

A small piece of membrane, exudation, or mucus is broken up or smeared over 
a covered glass, and the latter dried by passing it several times through the flame of 
a spirit lamp, taking care not to overheat. A few drops of a solution of Loeftler's 
potash-methylene blue are placed on the dried exudation for five minutes ; the 
cover glass is then again dried, a drop of balsam placed on it ; it is then placed on 
a glass slide and examined with a -, 1 .,- oil immersion. The D-bacilli may usually be 
recognised by the characters already given (p. 280). It must be admitted, however, 
their morphological characters are often not decisive. 

Cultivations on blood-serum and injections of the medium used for cultivations 
into guinea-pigs may be necessary in some cases of a doubtful nature. 



Table of Average Heights and Weights from Birth to Fourteen Years (Rotch). 



Boys 




Girls 






Age 






Height 


Weight 


Height 


Weight 


inches 


lbs. 




inches 


lbs. 


i9'75 


7*15 


Birth 


19-28 


6*93 


24*75 


14*30 


5 months 


23*25 


.13*86 


29'53 


20 -98 


1 year 


29-67 


19-8 


33*82 


30-36 


2 years 


32*94 


29-28 


37-06 


34-98 


3 „ 


36-31 


3315 


39'3i 


37*99 


4 ^ 


3S-8o 


36-36 


4i*37 


4i 


5 1 > 


41-29 


39*57 


43*75 


45*o7 


6 ,, 


43*35 


43'l8 


45*74 


48-97 


7 >> 


45*52 


47 * 30 


47*76 


53"8i 


S ,, 


47 58 


5i*56 


49-69 


59 


9 ., 


49 '37 


57 


51-68 


65-16 


10 


5i*34 


62-23 


53*33 


70-04 


11 ,, 


53*42 


68-7 


55*ii 


76-75 


12 


55*S8 


78-16 


57*2i 


S 4 -6 7 


13 „ 


58-16 


88-46 


59*83 


94*49 


14 „ 


59*94 


9823 


AT. B.— The 7 


veivhts during 


first three rears are ' 


vithout clothes : 


after third veai 



in ordinary indoor clothes. 



Appendix 



865 



FORMULA 



The doses given are suitable j 


■>r an infant of a year old unless otherwise stated. 


DISORDERS OF 


DENTITION, p. 63 




(1) 




(la) 




Potassii bromidi 


gr. iiss 


Chloralis 


• gr. ij 


Tr. hyoscyami 


TT[ V 


Potassii bromidi 


• g r - ij 


Ext. glycyrrh. fl. 


TIL X 


Sp. amnion, aromat. 


. m ij 


Aquas . . . . q. s. 


ad 3 j 


Syrupi pruni Virg. 


. HI X 


Every two or three hours, for ail infant 


Aquae 


q. s. ad 3 j 


of seven months. 




Every two or three hours. 


(2) 




(3) 




Hydrargyri chlor. mit. . 


gr. ss 


Sodii boratis . 


3 ss 


Euonymin .... 


gr. ss 


Tr. myrrhae . 


. 3ss 


Sacchari .... 


gr. ss 


Glycerini 


• 3 j 


The powder at night. 




Aq. rosae 


• 1 j 



To be painted on the gums or aphthous 
patches. 



CATARRHAL STOMATITIS, p. 65-6S 
(4) 



Potassii chloratis . 
Syrupi aurantii 
Aquae . . . . q. 

Three times a day. 



Acidi borici 
Sp. thymol 

Glycerini 
Aquae 



(5) 



(1-10) 



q. s. 





(4a) 




g r - j 


Potassii chloratis 


gr. j 


TIL xv 


Ext. cinchonae fl. . 


TTL V 


ad3j 


Elixir aromat. 


TTL V 




Aquae . . . . q. s 


. ad 3 j 




Three times a day. 






(6) 




gr. x 


Sodii bicarb. .... 


3j 


TTL V 


Sp. thymol .... 


3j 




Glycerini .... 


3 ij 


3ss 


Aquae . . . q. s. 


ad § viii 


adlj 


As a mouth-wash for children. 



To be painted on the aphthous patches. 

ACUTE TONSILLITIS, p. 74 

(7) 

Tr. aconiti . . . • Tr l j 

Liq. ammon. citratis. (Br.) . 3 j 

Syrupi aurantii . . . TIL xx 

Aquae . . . . q. s. ad 3 ij 

Every three hours, for a child of five 
years. 



( 8 ) 

Sodii salicylatis . . . gr. v 

Potassii citratis . . . gr. v 

Syrupi pruni Virg. . . TTL xx 

Aquae . . . . q. s. ad 3 ij 

Every three hours, for a child of five 

or six years. 



866 



Diseases of Children 



(9) 
Iodi ... . gr. iij 

Potassii iodidi . . • 3 j 

Glycerini . . . q. s. ad § 

Pigment for enlarged tonsils. 



(io) 
Aluminis . . . . 3 ij 

Acidi tannici . . , 3ss 

Glycerini . . . § ss 

Aquae rosae . . . q. s. ad 5 ij 
Pigment for enlarged tonsils. 



FLATULENCE AND COLIC, p 

(ii) 

. gr. iiss 



^4 



Magnesii carb 
Rhei . . . . . gr. \ 

Syrupi zingiberis . . TIL v 

Aq. menth. pip. . . q. s. ad 3 j 

Every two hours, for an infant three or 

four months old. 
(TH,-J — "TLj of nepenthe may be added to 
'each dose if the infant is under close 
observation.) ♦ 



(12) 

Chloralis .... 

Aq. laurocerasi. (Br.) . 
Syrupi pruni Virg. 
Aquae . . . . q. s. 

Every three hours. 



gr. iiss 
ni x 
tti x 

ad 3 j 



(13) 




(14) 






Sodii bicarb. 


gr. iiss 


Hydrargyri cum creta 




gr. i 


Sp. ammon. foetid. (Br.) 


• TTL ij 


Pulv. ipecac et opii 




gr. \ 


Sp. chloroformi 


• m j 


Sacchari 




gr. \ 


Aquce anethi. (Br.) . q. 


s. ad 3 j 


Ft. pulv. 






Occasionally. 












VOMITIN( 






(15) 




(16) 






Sodii bicarb. 


gr. iiss 


Liq. bismuth et ammor 


.citr.(Br 


)m v 


Aq. laurocerasi. (Br.) 


. TTI X 


Tr. nucis vomicae . 




TTI SS 


Sp. chloroformi 


• m j 


Glycerini 




m x 


Aq. anethi. (Br.) . 


• ad3j 


Aq. carui. (Br.) . 




ad3j 


Every four hours. 




Every four 


hours. 




SIMPLE DIARRHCEA, p. 87 






(17) 




(18) 






01. ricini 


. tti xv 


Sodii bicarb. 




gr- ij 


Acaciae .... 


• gr. v 


Bismuth, subcarb. . 


. 


gr. iss 


Syrupi zingiberis . 


. m v 


Tragacanthae 




gr- j 


Aq. menth. pip. 


. ad3j 


Sp. chloroformi 




TIL iiss 


Every two hours. 




Aq. cinnamomi 

Every four 


hours. 


ad3j 


(19) 




(20) 






Zinci oxidi 


gr. iss 


Acidi nitrici dil. 




m j 


Tragacanthoe . 


• g r - j 


Syrupi aurantii 




TTI X 


Sp. chloroformi 


• m j 


Decocti granati radicis. 


(Br.) q 


s. ad 3 j 


Glycerini 


. TT[ XV 


Every four 


hours. 




Aq. anethi 


. ad 3 j 









Every four hours. 



Appendix 



867 



(21) 




Acidi nitro-hydrochlorici dil. 


mj 


Liq. peptici 


m xx 


Sp. chloroformi 


mj 


Aq. aurantii flor. 


ad 3 j 


Three times a day. 





CONSTIPATION, p. 8S 



(22) 



Acidi sulph. aromat. . TTt j 

Magnesii sulphatis . . 3 ss 

Ferri sulphatis . . . gr. \ 

Sp. chloroformi . . TT[ y 

Aquae . . . . q. s. ad § ss 

Two or three times a day before meals, 
for a child of ten or twelve years. 

(24) 
Tr. belladonna . . TT[ v 

Tr. nucis vomicae . . T^ \ 

Syrup, sennae . . . ttj, x 

Inf. gentianae co. (Br.) . . ad 3 j 

Three times a day, for a child of three 
or four years. (Eustace Smith.) 



(23) 



Podophylli . . • . gr. £ 

Euonymin .... gr. £ 
Ex. cascara sag. . . . gr. j 

I)i Palatinoids (Oppenheimer) one or 
two a day, for a child of six to twelve 
years. 

(25) 

Ex. cascara sag. liq. ' . . TTJ, v 

Tr. belladonna? . . . Trj, v 

Elixir aromat. . . tt^ x 

Aquae . . . . q. s. ad 3 j 
A t bedtime. 



ACUTE GASTRIC CATARRH, p. 90 



(26) 




(27) 




Acidi hydrocyanici dil. . 


m j 


Sodii bicarb. . 


• gr. x 


Sp. chloroformi 


m j 


Aq. laurocerasi. (Br.) . 


. m xv 


Aq. aurantii flor. 


ad3j 


Aq. aurantii flor. 


• |ss 


Every three Jiours. 




Acidi citrici 


• g" r - v 






Aquae . . . . 


q. s. ad 3 ij 



The alkaline and acid mixtures to be 
taken effervescing every four hours, for 
a child of ten or twelve years. (Burney 
Yeo.) 



ZYMOTIC DIARRHOEA, p. 96 



(28) 



(29) 



Sodii salicylatis 


• g r - j 


Moschi ..... gr. \ 


01 ricini 


. m XV 


Acaciae . . . . . gr. v 


Acaciae . 


. gr. v 


Elixir aromat. . . . Til v 


Syrup, zingiberis 


. Til v 


Aq. rosae . . . q. s. ad 3 j 


Aq. menth. pip. 


q. s. ad 3 j 


Every two hours. 



Every two hours 



868 



Diseases of Children 



(30) 

Bismuthi salicylates . . gr. j 

Sp. ammon. arom. . . Ht ij 

Pulv. tragacanth. co. (Br.) . gr. j 

Sp. chloroformi . . . ^l j 
Aq. carui. (Br.) . . q. s. ad 3 j 
Every three hours. 



Or) 

Salol ..... gr. ij 

Pulv. tragacanth. co. (Br.) . gr. j 

Elixir aromat. . . ill v 

Aquae . . . . q. s. ad 3 j 
Every two hours. 



CHRONIC DIARRHCEA, p. 109 



(32) 




(33) 


Extracti haematoxyli 


gr. iiss 


Argenti nitratis . . . gr. v 


Tr. catechu . 


TU V 


Aquae . . . . O ss 


Syrupi tolu 


i'l x 


To be used as an enema. 


Aq. cinnamomi 


ad3j 




Every four hours. 







CHRONIC GASTRO-INTESTINAL CATARRH, p. 109 



(34) 
Sodii bicarb. . . . . gr. ij 

Pepsini . . . . . gr. j 

Sacchari . . . . gr. j 

Half an hour after meals. 



(35) 
Sodii bicarb. . 
Hydrargyri cum creta 
Pulv. rhei co. 
Sacchari 



gr. i 

gr. i 
gr. I 
gr- j 



(36) 
Acidi nitrici dil. 
Liq. helaline et pepsin co. 
Sp. chloroformi 
Aq. aurantii flor. 

Three times a day 



(38) 



Half an hour after meals. 

(37) 
TI[ iij Acidi hydrochlorici dil. . . TI[ iij 

3 ss Liq. euonymin et peps. co. 

TTL ij (Oppenheimer) . . '_ ss 

3 iij Elixir aromat. . . tt^ xv 

Aquae . . . . q. s. ad 3 iij 

Three times a day. 

{For children of seven to ten years.) 



Sodii bicarb. . 


. gr. v 


Inf. rhei. (Br.) . 


• 3j 


Elixir aromat. 


. Til XV 


Aquae 


q. s. ad 3 iij 



Three times a day before meals. 



(39) 

Potassii bicarbonatis . . gr. v 

Tr. nucis vomicae . . ttl j 

Aq. laurocerasi. (Br.) . '. tt[ xv 

Elixir aromat. . . TIX xv 

Aquae . . . . q. s. ad 3 iij 
Three times a day before meals. 

{For children of seven to ten years.) 

(4o) 
Acidi nitrici dil. . . • "H, iij 

Ext. cinchonae fi. . . ... Til v 

Syrup, aurantii . . 3 ss 

Aquae . . . q. s. ad 3 iij 

Three times a day after meals, for children of seven to ten years. 



Appendix 



869, 



TUBERCULAR ULCERATION OF THE BOWELS, p. 148 



Hydrargyri cum creta . . gr. j 

Pulv. ipecac et opii . . gr. ij 

Every night, for a child of five years. 

(43) 
EmuJs. ol. morrhiue B.P.C. 

One to three teaspoon ft Is three times a 
day. 



(45) 

Byno-hypophosphites (Allen & Hanbury). 
One to three teaspoonfuls three times a day, 

SCARLET FEVER, p. 264 



(42) 
Pulv. kino co. (Br.) . . gr. i-iJ 

Sacchari . . . . . gr. ij 

Every night, for a child of five to seven- 
years. 

(44) 
" Bynol" (Allen & Hanbury). 

One to three teaspoonfuls three times a 
day. 



(46) 




(47) 




Potass, chlorat. 


• gr- v 


Ammon. carb. . 


. gr. v 


Ext. cinchon. fl. 


. TTl V 


Ex. cinchon. fl. . 


. TT[ V 


Elixir aromat. 


TTl XV 


Tr. digitalis 


. m V 


Aquce . . . q. 


s. ad 3 iij 


Syrup, aurant. . 


. TT[ XX 


Every four hours, for a chila 


' of five to 


Aquae . . q. 


s. ad 3 iij 


eight years. 




Every four hours, for a child of five to- 






seven years. 






MEASLES 




(48) 




(49) 




Antimonii et potassii tartrat. 


gr- 3-0 


Tr. aconiti 


• m j 


Liq. amnion, acet. 


. ill XX 


Liq. ammon. citrat. (Br.) 


. TTl xx 


Syrup, tolu . 


TTl XV 


Elixir aromat. . 


. TTl X 


Aquae . . . . q. 


s. ad 3 ij 


Aquae . . . q. 


s. ad 3 ij 


Every four hours, for a child of five 


Every four hours, for, a 


child of five 


years. 




years. 





(50) 

Antipyrini . . . . gr. iii-v 

Sp. chloroformi . . TT^ iij 

Elixir aromat. . . . TT[ x 

Aquae . . . . q. s. ad 3 iij 

Every six hours, for a child of six 
years. 



(52) 
Tr. belladonna; . 

Extr. cannabis ind. 

Glycerini 

Aquae . 

Every six hours, for a child of three to 

five years. 



INFLUENZA, p. 293 

(5i) 
Sodii salicylat. . . gr. v 

Liq. ammon. acet. . . 3 ss 

Syrup, tolu . . 3 ss 

Aquce . . . q. s. ad 3 iij 

Every six hours, for a child of six to 

eight years. 

WHOOPING COUGH, p. 316 

(53) 
Antipyrini . . . gr. iij 

Elixir aromat. . . . TTi, x 

Aqua? . . . q. s. ad 3 ij 

Every six hotirs, for a child of three to- 

five years. 



. TTl V-XV 

• gr. \ 

. TTl XV 

s. ad 3 ij 



8;o 



Diseases of Children 



(54) 
Pot. bromidi 

Liq. morphix* hyd. (Br.) 
Syrup, scilire 
Aq. aurant. flor. 
Every six hours, for a child of six to 
eight years. 



gr. v 

Tr l j 

TU XX 

ad 3 ij 



(55) 

Bromoform. 

Two or three drops in a teaspoonfnl of 

water every four hours. 



CATARRHAL LARYNGITIS, p. 33Q 



(56) 



Antimonii et potassii tartatris 
Liq. ammon. citr. (Br.) 
Elixir aromat. 

Aquae . . . q. 

Every four hours, for a child of two to 
three years. 





(57) 






gr. 21J 


Apomorphinae hydrochlor. 




• gr.^ 


TTi x 


Yin. ipecac 




• m ij 


m V 


Elixir aromat. 




. m v 


ad 3 j 


Aquae .... 


q- 


s. ad 3 j 



Every four hours, for a child of two to 
three years. 



BRONCHITIS AND BRONCHO-PNEUMONIA, p. 362 



(58) 
Codeinae . . . . gr. \ 

Elixir rubrum . . TT[ y 

Aquae . . . q. s. ad 3 j 

Occasionally, for a child of five or six 
years. 



(60) 
Ammon. carb. 
Tr. digitalis . 
Syrup, scillae . 
Aq. anethi. (Br.) . 

Every four hours. 

(62) 
Tr. capsici § 

Lin. saponis § 

To be applied to the affected part 

(64) 
Vini ipecac. . . ill ij 

Liq. ammon. citratis. (Br.) fT\, x 
Syrup, tolu. . . ni x 

Aquae . . . q. s. ad 3 j 

Every four hours. 



g r - J 

nj 

TTl XX 

ad 3 j 



(59) 

Liq. morphinae hydrochlor. (Br.) TT^ ij 

Acid. nitr. dil. . . TU j 

Syrup, aurant. . . . ^ xx 

Aquae . . . . q. s. ad 3 j 

Occasionally, for a child of eight to ten 
years. 

(61) 
Ol. sinapis volat. . . TIJ, x 

Lin. camph. . . • 1 j 

To be rubbed on the affected part. 



(63) 
Capsici . . . 3 j 

Adipis lanae hydros. . § j 

To be applied to the affected part. 

(65) 
Antimonii et potassii tartrat. . gr. -gV 
Liq. morphiae hydrochlor. (Br.) TTl j 
Aq. laurocerasi. (Br.) . K . TT[ x 
Elixir aromatici . . . TT[ x 

Aquae . . . . q. s. ad 3 ij 

Every four hours, for a child of five to 
six years. 



Appendix 



87 



(66) 
Potass, bicarb. 


• gr. j 


(67) 
Sodii bicarb gr. x 


Potass, iodidi . 


• gr. \ 


Glyc. acid, carbolici . " j 


Ext. cinch, fl. . 
Syrup, scillae . 
Aquae 

Three times 


. m ij 

. TT[x 

q. s. ad 3 j 
a day. 


Aquas . . . . q. s. ad § j 

To be used with Siegle's steam spray. 

(Burney Yeo.) 



ACUTE PNEUMONIA, p. 373 

(68) (69) 

Tr. aconiti . . Ttx j 

Liq. ammon. acet. . . i'l xv 

Aq. laurocerasi. (Br.) . T7[ x 

Elix. aromat. . . . TT[ x 

Aquae . . . q. s. ad 3 ij 



TT[ I 
TTL ij 

^ j 



Liq. strychniae . 
Tr. digitalis 
Sp. chloroformi 

Aq. aurant. flor. . . ad 3 j 

Every four hours, for a child of two or 
four years. 



Every four hours, for a child of two to 
five years. 



(7o) 
Antimonii et potassii tartratis . gr. -}-$ 
Liq. morphia; hyd. (Br.) . V\ ij 
Potass, iodidi . . . gr. ij 

Sp. chlor. . . . TT|_ ij 

Aquae . . . . q. s. ad 3 ij 
With an equal quantity of water every 
three hours, for a child of five or six 
years. (Burney Yeo.) 



STHMA, p. 387 






(7i) 






Pot. iodidi 




■ gr- 2i 


Ext. stramonii . 




• g r - TT 


Sp. chlorof. 




. til v 


Sp. ammon. aromat. 




. Tl[ v 


Aquce 


q- 


s. ad 3 ss 



Three times a day (Burney Yeo), for a 
child of ten years. 



TUBERCULOSIS 


(72) 




01. morrhuae .... 


3 ss , 


Extr. of malt .... 


ad 3 j 


Three times a day. 




Lin. iodi. 


(Br.) 


Glycerini 




Aquae 





OF LUNGS, p. 



394 

(73) 



(74) 



Ol. morrhuae . . . . 3 j 

Creasoti . . . . . T>1 -£ 

Three times a day after food. ( Very 
nauseous.} 



q. s. 



5i] 

ad § iss 



Pot. bicarb. 
Tr. aconiti . 
Sp. chloroformi 
Aq. aurant. flor. 



(75) 



To be painted over the affected part. 
PERICARDITIS, p. 416 



(76) 



• gr- x 

• R ij 
. TT[ y 

q. s. ad § ss 
Every six hours, for a child of eight to 
ten years. 



gr. x 

3 ss 
3 ss 



Sodii salicylat. 
Liq. ammon. acet. 
Syrup, aurant. 
Aquae 

Every six hours, for a child of eight to 
ten years. 



s. ad 



$72 



Diseases of Children 





CARDIAC 


TONICS, p. 416 




(77) 




(78) 




Tr. ferri chlor. 


. m v 


Ferri et ammon. citr. . 


. gr. v 


Tr. digitalis 


. m v 


Liq. strychnine. (Br.) 


. m ij 


Sp. chloroformi . 


. TTL V 


Sp. chloroformi . 


. TTL v 


Aquas 


q. s. ad § ss 


Glycerioi 


. TU XV 






Aquae 


q. s. ad § ss 


Three times a day, for a child of eight to 


Three times a day, for a 


child of eight to 


twelve years. 


twelve years. 


DIURETICS IN CARDIAC DROPSY, p. 4 


17 


(79) 




(80) 




Pot. acetatis 


• gr. x 


Pot. iodidi 


• g r - ij 


Sued scoparii 


3 ss 


Tr. scillas . 


. TFlV 


Tr. digitalis 


. TTL V 


Tr. strophanthi . 


. tilv 


:Sp. chlor. . 


. m v 


Sp. chlor. . 


. til v 


Inf. senegas. (Br.) 


. 3 SS 


Aquas 


q. s. ad 1 ss 



Three times a day , for a child of eight to 
twelve years. 



Three times a day, for a child of eight to 
eleven years. 



CARDIAC STIMULANTS, 



(81) 
Sp. astheris co. 
Tr. nucis vorrr*. 
Tr. lavandulas co. 
Aq. carui. (Br.) . q 

Every fottr hours or as required, 

for a cJiild of eight to twelve years. 

(Burney Yeo.) 



. TT[ x 

Til V 
Til X 

s. ad § ss 



p. 417 

(82) 
(Br.) 



Liq. strychniae. 
Ex. cocas fl. 
Sp. chloroformi 
Aq. cinnamomi 

Every four hours, 

for a child of eight to twelve years. 

(Burney Yeo.) 



TTL ij 
TTL XV 
TTL V 

ad ? S! 



RHEUMATISM, p. 460 



Sodii salicylat. 
Pot. bicarb. 
Syrup, aurant. 
Aquas 



(83) 



• gr. x 
. gr. x 

3 ss 
q. s. ad § ss 



Potass, citratis 
Syrup, limonis. 
Aquas 



(84) 
(Br.) 



q. s. 



gr. x 

3 ss 
ad^ss 



Every four hours, for a child of ten years. Every four hours, for a child of ten years. 
EPILEPSY AND CONVULSIONS, pp. 531 and 536 



Potass, bromid. 


. gr. vij 


Potass, bromid. 


■ gr. v 


i"r. belladonnas 


. TTL X 


Sodii bicarb. . 


• gr. v 


Sp. ammon. aromat. 


. in, x 


Rhei 


• • gr- 1 


Syrup, aurant. . 


3 ss • 


Sp. chloroformi 


. til v 


Aquas 


q. s. ad § ss 


Aquas 


q. s. ad § ss 


Three times a day, for 


7 child of eight 


Three times a day, for 


a child of eight 


years. 




years. 





Appendix 



873 



Sodii bromid. .... gr. v 


Potass, bromid. 




• gr. iij 


Elixir cascara sagrad. . TTL x 


Syrup, aurant. 




. ill x 


Sp. ammon. aromat. . TT| y 


Sp. chloroformi 




. mj 


Aquae . . . q. s. ad § ss 


Aquae 




q. s. ad 3 j 


Three times a day, for a child of eight 


Every tzvo hours 


, for an 


infant of six 


years. 


months. 




(89) 




(90) 




Potass, bromid. . . . gr. iiss 


Chloral. 




gr. iiss 


Chloral. .... gr. iiss 


Nepenthe 




. J*U 


Syrup, aurant. . . tij, xv 


Elixir aromat. 




. m v 


Aquae . . . q. s. ad 3 j 


Aquae 




q. s. ad 3 j 


For an infant of a year old. 


For an infant of a 


year old. 


NEPHRITIS^ 


pp. 265 and 607 






(91) 




(92) 




Potass, citratis . . . gr. xv 


Potass, tart. . 




. gr. xv 


Syrupi limonis. (Br.) . TT[ xx 


Syrup, aurant. 




. 3ss 


Aquae . . . q. s. ad § ss 


Aquae 




q. s. ad § ss 



Every four hours, for a child of six to 
ten years. 

(93) 



Every fotir hours, for a child of six to 
ten years. 

(94) 



Liq. ammon. acet. . 


3 ss 


Tr. ferri chlor. 


. m v 


Tr. digitalis 


. TTl V 


Acid. acet. dil. 


• m ij 


Sp. chlorof. 


. TH, V 


Liq. ammon. acet. . 


3 ss 


Aquae 


q. s. ad § ss 


Sp. chlorof. 


. m v 






Aquae 


q. s. ad 1 ss 



Every four hours, for a child of six to 
ten years. 



Every four hours, for a child of six to 
ten years. 



EC2 


5EMA AND I 


MPETIGO, p. 784 




(95) 




(96) 




Hydrarg. chlor. mit 


• gr- i 


Hydrarg. c. cret. 


■ gr- 1 


Euonymin 


• gr- i 


Pulv. rhei co. . 


• gr- i 


Sacchari . . . . 


■ gr- j 


Sacchari .... 


• gr- j 


Every oth 


er night, for an 


infant of six months old. 




(97) 




(9§) 




Ol. morrhuae . 


■ Sij 


Ichthyol .... 


• Iss 


Liq. potass, arsenit. 


• 3j 


Carron oil . . 


. O ss 


Mucilaginis acaciae . 


. q. s. 


To be applied on lint. 




Syrup, aurant. 


• § j 






Aquae 


q. s. ad § iv 






One teaspoonful three tint 


es a day after 






food. 









8 7 4 



Diseases of Children 





(99) 




(100) 




Calamine preparat. (Br.) 


3 ij 


Liq. plumb, subacetatis . 


z ss 


Zinci oxidi 




3ss 


Tr. opii .... 


3 i j 


Ol. oliv. . 




• 1) 


Aquae . . . q. 


s. ad 5 v 


Liq. calcis 




• 1) 


Ft. lotio. 




(Crocker.) 










(IOI) 




(102) 




Acid, boric. . 




3 j 


Zinci oxidi 


gr. xx 


Ol. amygdalae t> 


press 


3x 


Acid carbolici 


gr. x 


Cerae alb. 




7 i 


Oleum rosre 


Til SS 


Cetacei . 




3 j 


Ung. lanolini . 


|ij 


Aq. rosce 




3x 


Ft. ung. 




Ft. ung. 


(103) 




(104) 




Acid, salicylates 




• gr. x 


Sulphur precip. 


gr. xx 


Zinci oxidi 




3 ij 


Lanolini .... 


3 ij 


Amyli 




• 3 ij 


Vaselini . • . 


3 ij 


Vaselini . 


(105) 


. §ss 


Zinci oxidi 

Amyli .... 

(106) 


3 ij 
3 ij 


Ung. hydrarg. ox. flor. . 


j 


Ung. hydrarg. ox. rubri . 


3 ss 


Five per cent. 


ess. vaseline. 
(107) 




Ung. zinci oxidi 
Cerati petrolii 

(108) 


3 j 


Glyc. plumb, acet. 


3 ij 


Sulphur, precip. 


3 ss 


Liq. carbonis deterg. 


• 3 ij 


Camphor.' 


gr. xv 


Aq. rosae 




• Svj 


Ung. zinci oxidi 

Amyli .... 

Cerati petrolii 


3 ii 

• 3 ii 

• 3i 



PSORIASIS, p. 791 



(log) 




(no) 


01. cadini 


3 ss Chrysarobini 


_. 3j 


Ung. hydrarg. amnion. 
Ung. . . 


3 ij Gutta-perch?e 
3 j Chloroform i 
To be applied to the affected parts. 


• 3j 
3 x 


(in) 


TINEA, pp. 793 and 795 


(112) 


Sulphur, precip. 
Hydrarg. ammoniati . 
Thymol 
Vaselini . 


3 j Sod. borat. . 
3 ss Spir. camph. 
gr. x Glycerini 
3 j Aq. aurant. flor 


. 3j 
. 3j 
. 3 ij 

q. s. ad § iv 


Ung. . . . 


ad ^ iv j' i) £ usea 


as a hair-wash. 



Appendi. 



375 



(113) 






Tr. cantharides 


3 ij 


Tr. cantharid. 


Tr. capsici 


3 ij 


Tr. capsici 


Tr. nucis vomicae 


3 ss 


01. ricini . 


01. ricini . 


3 ij 


Alcohol 


Eau de Cologne 


ad % iv 


To be us 


To be used as a 


hair-wash. 





(H4) 



§ss 

|ss 

?iv 



(IT5) 



SCABIES, p. 796 



(116) 



Sulphuris . 


3j 


Styracis 


?ss 


Balsam Peru 


3ss 


Ung. simplicis . 


§iss 


Ung. simplicis . 


Sj 


(117) 






Naphthol 


. • . 3j 






Ung. simplicis 


• • • Sij 





INDEX 



Abces peribronchique, 360 
Abdomen, examination of, 82 
Abdominal abscess, 124 
Abdominal pain in spinal disease, 719 

— injuries. 801 

— section in intussusception, 140 

— wall, hiatus of, 155 
Abortive pneumonia, 369 
Abscess, acute glandular. 239 

— alveolar, 68, 655 

— cerebral, 498, 760, 762 

— chronic, 244, 841 

— glandular, 244 

— hepatic, 190 

— iliac, 127 

— in bone, 654, 841 

— in hip disease. 694, 841 

— of the liver, T90 

— of the lung. 375 

— mediastinal, 389 

— parosteal, 637 

— pelvic, 695 

— periarticular, 693 

— periesophageal, 78, 80 

— periglandular, 240 

— periosteal, 637 

— perisigmoid, 126. 127 

— peritoneal, 120-127 

— perityphlitic, 122-124, 127 

— post-pharyngeal, 78 

— psoas, 697, 698, 715, 724 

— residual, 701, 706 

— retro-cesopbageal, 78 

— sacral, 726 

— spinal, 715, 717 
Absence of mouth, 177 

— of tongue, 175 
Accidental idiocy, 556 
Accidents with anaesthetics, 824 
A. C. E. mixture. 820 
Acetabular disease, 6S8 et seq. 
Acetabulum, ' travelling,' 689 
Acquired clubfoot, 727 

— hernia, 156 

— syphilis, 446 

— talipes, 727 



Acromioclavicular joint, disease of, 685 
Acute adenitis, 239, 240 

— atrophic paralysis, 578 

— bronchitis, 351 

— cerebral congestion, 247 
■ paralysis, 504 

— circumscribed osteomyelitis, 645 

— epiphysitis, 646 

— gastro-intestinal catarrh, 90 

— generalised broncho-pneumonia, 360 

— glandular abscess, 239 

— hip-disease, 690, 844 

— meningitis, 447 

— miliary tuberculosis, 232 

— necrosis, 637 

— nephritis, 603 

— orchitis, 318, 628, 630, 631 

— osteomyelitis, 645 

— periostitis, 636 et seq., 637 

— peritonitis. 118 

— rickets, 200 

— simple serous synovitis, 667 

— suppurative arthritis of infants, 670 

— tonsillitis, 70 

— tuberculous synovitis, 672 

— yellow atrophy of liver, 184 
Acutely inflamed tonsils, removal of, 76 
Addison's disease, 607 

Adenitis, acute, 239, 240 

— tuberculous, 237 
Adenoids, post-nasal, 77 
Adenomata recti, 163 
Adjacent abscess, 693 
Adolescence, rickets of, 216 

— synovitis of, 710 
Adrenals, disease of, 607 

Age for operation in hare-lip, 16S 
Air-passages, foreign bodies in, 346 
Albuminuria in healthy children, 594 

— in diphtheria, 284 
Alimentary canal, 6 
Alopecia areata, 796 

Alum in whooping-cough, 316 
Alveolar abscess, 68, 655 
Amputation at hip-joint, 711 

— intra-uterine, 744 



8/8 



Index 



Amputation, primary, 812 
Amussat's operation, 152 
Anosmia, 432 

— idiopathic. 434 

— lymphatica, 439 

— pernicious. 434 

— splenic, 437 

— with oedema. 433 
Anaesthetics, 816 
Anal condylomata, 163 

— fissures, 164 

— fistula, 163 

Anastomosis, aneurism by, 428 
Anchyloglossus, 175 
Aneurism, 430 

— by anastomosis, 428 

— of middle cerebral artery, 431, 514 
Angina Ludovici, 245 

Angioma, cavernous, 422 

— lymphatic, 428, 767 

— simple, 421 

Angular curvature of spine, 713, 847 
Ankle, excision of, 681 

— tubercular diseases of, 666 
Ankylosis of jaw, 685 
Anterior polio-myelitis, 578 
Antipyretics, 854 
Antitoxin, 287 

Anus, artificial, 152 

— imperforate, 150 

— ulceration of, 164 
Aortic regurgitation, 413 
Aphasia, 550 
Aphthous stomatitis, 64 

— vulvitis, 625 
Apoplexia neonatorum, 19 
Appendicular peritonitis, 122 
Appendix, intussusception of, 142 

— removal of, 127 
Arm, fractures of, 811 

Arrest of growth after epiphysitis, 644 

in rickets, 209, 216 

after injury, 803, 807, 808 

Arterial nsevus, 421 
Arterio-venous varix, 427, 428 
Arteritis, 33 
Arthrectomy, 676 et seq. 
Arthritis deformans, 461 

— with glandular enlargement, 462 

— of infants, acute suppurative, 670 

— rheumatic, 461, 669 
Arthrodesis, 736 

Artificial muscle, 733, 737, 740, 849 
Ascaris, 115 
Ascites, 116 

— in cirrhosis, 186 
Asphyxia neonatorum, 17 



Aspiration for empyema, 3S1 
Asthma, 386 
Asymmetry, 851 
Athetosis. 504, 50S, 556 
Athrepsia, 103 
Atlanto-axial disease, 713 
Atresia ani, 150 

— oris, 177 
Atrophy of brain, 489 

— of face, 177, 742 

— gastro-intestinal, 103 

— of jaw, 685 

— of liver, acute yellow, 184 

— muscular, 590 

— progressive muscular, 586 

— simple, 103 
Auricle, disease of, 758 

— supernumerary, 178 
Auscultation, 322 

Axis traction for hip-disease, 704, 846 



Bagillus, Gaertner's. 101 

Backward children, 557 

Balanitis, 624 

Barley water, 51, 852 

Barwell's artificial muscle, 733, 737, 740 

Basal ganglia, tumours of, 496 

Belladonna in whooping-cough, 317 

Biedert's cream mixture, 48 

Bifid anus, 150 

— tongue, 176 

— uvula, 167 

Bile-ducts, stricture of, 182, 1S3 

— secretion of, 7 
Birth, circulation after, 4 

— diseases incident to, 17 

— marks, 42 T 

— palsy, 502 
Bladder, calculus of, 609 

— extroversion of, 617 

— inflammation of, 613 

— rugous, 613 

— tuberculous disease of, 613 

— tumours of, 613 
Bleeders, 28, 34, 440 
Bleeding, 814 

— after excision of tonsils, 76 
Blennorrhagia, 32 

Blood, -amount in body, 5 

— of infant, 5 
Body-weight, 10 
Bone grafting, 802 
Bones, diseases of, 636, 841 

— syphilitic disease of, 452, 454, 649, 

659 
Boric acid in diphtheria, 2SS 



Index 



879 



Bowels, chronic obstruction of, T42 

— congenital obstruction of, 148 

— tuberculous ulceration of, 144 
Bow-leg, 213, 836 

Brain, abscess of, 760, 762 

— atrophy of, 489 

— congestion of, 247, 468 

— cyst of, 491 

— development of, 8 

— hypertrophy of, 489 

— sarcoma of, 491 

— sclerosis of, 488 

— softening of, 484, 573 

— surgery of, 498, 760, 762 

— syphilis of, 454, 482 

— tumours of, 491 

— weight of, 8 
Branchial cartilages, 178 

— dermoid cysts, 180 

— fistulae, 178 

median, 179 

Bromide rash, 792 

Bronchial glands, adenoma of, 390 

— diseases of, 387 
Bronchiectasis. 353 
Bronchitis, 351 

— acute, 351, 360 

— chronic, 354 
Bronchocele, 777 
Broncho-pneumonia, 355 

— in measles, 270 

— acute generalised, 360 

— chronic, 358 

< — disseminated, 360 

— micro organisms in, 361 I 

— from tuberculosis, 233 
Bryant's splint, 702, 708 
Burns and scalds, 813 
Bursa of Fleischmann, 177 
Bursae in club-foot, 743 
Bursitis, 743 



CjECAL colotomy, 153 

— hernia, 157 

Calcaneo-astragaloid disease, 683 
Calculus of kidney, 602 

— in tonsils, 76 

— urethral, 610, 614 

— vesicas, 609 
Callisen's operation, 152 
Calomel fumigation. 336 
Calot's operation, 825 
Canal of His, 179 
Cancrum oris, 69 
Capillary naevus, 421 
Caput succedaneum, 23 



Carbolic acid in whooping-cough, 317 
Carcinoma of stomach, 113 
Cardiac dilatation, 414 
in nephritis, 260 

— murmurs, 413 

— syncope in diphtheria, 285 
Carditis, acute, 404 

Caries, 636 

— of spine, 713, 847 
Carpo-pedal contractions, 534 
Cartilages, branchial. 178 
Cartilaginous tumours, 765, 766 
Caseation of bronchial glands, 387 

— of lung, 390 
Catarrh, acute gastric, 90 
gastro-intestinal, 90 

— of bronchial tubes, 351 

— chronic gastro-intestinal, 103 
Catarrhal jaundice, 183 

— laryngitis, 329 

— synovitis, 668 

— tonsillitis, acute, 70 
Caudal appendage, 570 
Cavernous angioma, 422, 767 

— naevus, 422 

— sinus, thrombosis of, 763 
Cellulitis, deep cervical, 245 
Cephalhematoma, 21 
Cephalhydrocele, 800 
Cerebellar abscess, 498, 760, 762 
Cerebellum, tumours of, 493 
Cerebral abscess, 498, 760, 762 

— cyst, 491 

— haemorrhage, 501, 504 

— lesions, surgical treatment of, 499, 
760 

— paralysis, acute, 504 

— pneumonia, 370 

— sinuses, thrombosis of, 514 

— softening, 484, 513 

— tumour, 491 

— congestion. 247, 468 
Cerehro-spinal meningitis, 480 
Cervical cellulitis, 70, 245 

— paraplegia, 720 
Chest, examination of, 321 

— form of, in infancy, 321, 835 

— injuries of, 801 
Cheyne-Stokes respiration, 471 
Chilblains, 789 
Child-crowing, 323 
Childhood, 2 

Chloroform, 821 
Chlorosis, 432 
Cholera infantum, 90 
Chorea, 515 

— insaniens, 522 



88o 



Index 



Chorea, paresis in, 521 

— peripheral neuritis, 521 
Choroid, tubercles of, 233 
Chronic bronchitis. 354 

— broncho-pneumonia, 353 

— circumscribed osteomyelitis, 652 

— diarrhoea, 105 

— diffuse osteomyelitis, 654 

— gastro-intestinal catarrh, 103 

— hydrocephalus, 485 

— intussusception, 131 

— laryngitis, 348 

— nephritis, 605 

— obstruction of bowels, 142 

— periostitis, 648 

— peritoneal effusion, 117, 128 

— peritonitis, 117, 128 

— rheumatic arthritis, 461, 669 

— tonsillar hypertrophy, 74, 330 

— tonsillitis, 74 

— vomiting, 105 

Circulation, changes in, after birth, 4 

Circumcision, 623 

Cirrhosis of liver, 186 

Classification of bone inflammation, 

Clavicle, deficiency of, 752 

— fractures of, 810 
Clavus hystericus, 468 
Cleft of lower lip, 174 

— of palate, 171 
Clothing of infants, 39 
Club-foot, 727, 848 
Club-hand, 747, 851 
Club-leg, 740 
Coccygeal dimple, 569 
Colic, 84 

Collapse of lung, 353 
Colon, dilatation of, 142 
Colotomy, inguinal, 152 

— lumbar, 152 

Coma in meningitis, 471 
Compound congenital tumours, 772 
Compression of trachea, 329 
Condensing osteomyelitis, 656 

— ostitis, 637 
Condyloma of tongue, 177 
Condylomata, 177, 452 
Congenital deficiency of muscles, 743 

— deformities of digestive tract, 177 
of oesophagus, 180 

— dislocation of hip, 751, 851 

— heart-disease, 397 

— hernia, 156 

— hydrocele, 633 

— hypertrophy of oesophageal glands, 81 

— idiocy, 552 



Congenital laryngeal stridor, 322 

— mucoid cyst of tonsil, 74 

— naevus, 421 

— obstruction of bowels, 148 

— rickets, 203 

— sacral fistula, 569 
tumours, 772 

— stricture of bile-ductn, 1S2 
of oesophagus, 180 

— syphilis, 477 

— syphilitic periostitis, 452, 454, 649, 

659 

— tuberculosis, 228 

— tumours, 772 

— urethral anus, 150 
Constipation, 88 
Constriction of limbs, 746 
Contraction of meatus urinarius, 616, 

621 
Convulsions, 532 
Cord, separation of, 31 
Cortical layer, tumours of, 496 
Coryza, syphilitic. 448, 453 
Costo-vertebral disease, 726 
Coxalgia, 687 
Coxa vara, 211, 710 
Craniectomy, 559 
Craniotabes, 200 
Cream mixture, 48 
Creeping pneumonia, 370 
Cretinism, 559 

Croton chloral in whooping-cough, 317 
Croup, diphtheritic, 332 

— membranous, 332 

— spasmodic, 327 
Croupous angina, 290 

— exudation on navel, 32 

— pneumonia, 366 
Cryptorchism, 627 

Curvature of spine, angular, 713, 847 

lateral, 225, 837 

rickety, 210, 835 

— of tibia, 213 et seq., 836 
Cutaneous nsevus, 422 
Cyanosis, 398 

Cystic disease of testis, 633 

— growth of vulva, 627 

— lymphangioma, 428, 767 

— tumours, 767 et seq. 
Cystinuria, 594 
Cystitis, 613 

— tubercular, 613 

Cysts, dermoid, 164, 177, 180, 571, 635, 
768 et seq. 

— of jaws, 776 

— serous, 767 

— sublingual, 176, 767 



Index 



88 1' 



Dactylitis, syphilitic, 659 

— tuberculous. 657 
Deaf-mutism, 547 
Deafness, 759 

Deep cervical cellulitis, 245 
Deformities of oesophagus, 180 

— in rickets, 208, S35 

treatment of, 21S, 836 

rickets, operations, 220 

— of umbilicus, 154 

Deformity from thumb-sucking, 177 
Degenerated naevus, 423, 428 
Degeneration, reaction of, 581 
Dental formulae. 13 
Dentigerous cysts, 776 
Dentition, ailments of, 60 

— course of, 12 

— second, 63 
Depressed scars, 243 
Derbyshire neck, 777 
Dermatitis gangrenosa, 792 

— exfoliata, 792 

Dermoid cysts, 164, 177, 180, 571, 635, 
768, 769 et seq. 

branchial, 17S 

of rectum, 164 

Developmental idiocy, 556 
Deviation of nasal septum, 755 
Diabetes insipidus, 464 

— mellitus, 463 
Diaphragmatic hernia, 154, 160 
Diarrhoea, 86 

— chronic, 105 
— dysenteric, 99 

— lienteric, 87 

— in measles, 271 

— summer, 90 

— zymotic, 90 

Diet of infants, 56, 57, 828 

— tables for indigestion, Hi 
Digestive system, diseases of, 60 
Digitalis in heart-disease, 417 
Dilatation of the ventricles, 414 

— of stomach, 112 

— of colon, 142 
Dilator, tracheal, 340 
Diphtheria, 27S, 332, 371 

— antitoxin, 287 

— diagnosis of, 286 

— pathology of, 279 

— treatment of, 287 

— albuminuria of, 284 

— cardiac syncope in, 285 

— epidemics of, 279 

— infectious nature of, 279 

— laryngeal, 284. 332 

— malignant, 283 

56 



Diphtheria, mild, 282 

— paralysis in, 285 

— pharyngeal, 281 

— pneumonia in, 285 

— quarantine in, 289 

— bacillus of, 2S0 

— nasal, 283 

— prognosis in, 286 

— pseudo, 290 

— rashes in, 283 

— wound, 284 
Diphtheritic croup, 332 

— infection of navel, 32 

— paralysis, 285 

— sore throat, 290 

Direct tubercular infection, 145, 228 
Dislocations, 696, 750, 812 
Dislocation of elbow, 812 

— of hip, 696, 812 

■ congenital, 751, 851 

— of patella, 813 

— of shoulder, 812 

congenital, 751 

Displaced nasal septum, 755 
Disseminated broncho-pneumonia, 360 

— myelitis, 575 

Distribution of lymphatic glands, 237 
Diverticula of oesophagus, 79 
Diverticulum, Meckel's, 31, 155 
Double monsters, 745 

— hip disease, 712 

— hip splint for spinal caries, 722, 723 

— urethra, 622 
Dressings, Si 5 

' Dry bellyache,' 719 
Duck-toes, 740 
Ductus arteriosus, 4 
obliteration of, 4 

— venosus, 4 

Dyspeptic diseases of infancy, 83 
Dyspnoea from spinal abscess, 329 
Dysenteric diarrhoea, 99 
Dysphagia in spinal disease, 718 



Ear, closure of meatus of, 758 

— diseases of, 475, 477, 498, 758 

— foreign body in the, 758 
Early life, periods of, I 
Eclampsia, 532 

Ectopia vesicae, 617 

Eczema, 780 

Elbow, disease of, 664, 843 

— dislocation of, 812 
Embolism, 431, 511 

— in nephritis, 260 

— tubercular, 229 



ss. 



Index 



Emphysema, 353 

— in tracheotomy, 341 

— vicarious, 360 
Empyema, 375 

— from necrosis of rib. 643 

— surgical treatment of, 381 
Encephalocele, 570 
Enchondroma, 765, 773 et sec/. 
Encysted hernia, 156 
Endarteritis, 484. 
Endocarditis, 407 
Enlarged spleen, 436, 453 
Enteric fever, 293 

abdominal symptoms in, 296 

bronchitis and pneumonia in, 2c 

— ■ — contagious nature of, 294 

diagnosis of, 360 

epistaxis in, 297 

haemorrhage in, 297- 

incubation of, 294 

membranous tonsillitis in, 299 

mortality of, 294 

perforation of intestine in, 29S 

— — peritonitis in, 298 

pyaemia in, 298 

rash in. 296 

relapses in, 297 

symptoms of, 295 

temperature of, 295 

treatment of, 361 

tuberculosis in, 299 

Enucleation of tonsil, 76 
Enuresis, 614 
Epidemic influenza, 290 

— tonsillitis, 72 
Epilepsy, 526 

— trephining for, 531 

— post-hemiplegic, 529 
Epiphyses, separation of, S03 

— dates of union of, 810 
Epiphysitis, 636 et seg. 

— syphilitic, 454-456 
Epispadias, 620 
Epistaxis, 757 
Epithelioma of kidney, 597 
Erasion, 676 

— of ankle, 6S0 
Eruptions, drug, 792 
Erysipelas, 310, 639, 815 
Erythema, 310, 7S8 

— multiforme, 459, 788 

— nodosum. 460, 789 

— pernio, 789 

— scarlatiniforme, 788 
Estlander's operation, 385 
Ether, S21 
Examination of chest, 321 



Exanthematous periostitis, 649 

— synovitis, 256, 660, 668 
Excision, 677 

— of ankle, 681. 736 

— of hip, 704, 847 

— of knee, 677, 736 

— of tarsus. 682 
for club-foot, 735 

— of wrist, 843 
Excoriation of navel, 32 
Exostosis, 767 
Expectorants. 859 

Extension for hip disease, 702, 844 
External meatus of ear, closure of, 758 
Extravasation of urine, 610, 617, 801 
Extroversion of bladder, 619 
Eyes, syphilitic affection of, 454 



Face, atrophy of. 177, 742 

— hypertrophy of, 177 
Facial paralysis, 761 
Faecal fistula, 123, 125, 152 
False croup, 326 

— hydrocephalus, 94, 474 

— spina bifida, 568 
Fasting girls, 540 
Fat diarrhoea, 87 

Fatty degeneration, acute, 29 

— liver, 189 

— tumours, 770 
Favus, 796 

Feeble vitality in hare-lip cases, 167, 168 
Feeding, artificial, 44, 828 

— bottles, 56 

— of infants at the breast, 39 
Femoral hernia, 160 
Femur, fractures of, 811 

Fever, infantile intermittent, 300, 319 

Feverishness as a symptom, 246 

Fevers, 246 

Fibrocellular tumour of tongue, 77 

Fibrous tumours, 767 

Fingers, contraction of. 749 

Fissures of the anus. 164 

— of mouth in syphilis, 449 et seq. 

— of sternum, 752 
Fistula, in ano, 163 

— branchial,. 178 

— intestinal, 123, 125, 152 

— tracheal, 180 

— umbilical, 124 
Fits, hysteroid, 528 
Flat-foot, 738, 849 

— in genu valgum, 215, 216 
Flatulence, S4 
Flea-bites, 797 



Index 



883 



Foetal pericarditis, 403 

— peritonitis, 149, 150 

— rickets, 203 

Foetus, parasitic, 772, 774 

Fontanelles, closure of, S 

Foramen ovale, patent, 398 

Forcible straightening of limbs, 220, 836 

Foreign bodies in the air-passages, 346 

in ear, 758 

— — in nose, 754 

in oesophagus, 80 

Fracture after necrosis, 645 
Fractured base of skull, 801 
Fractures, green-stick, 802, 837 

— of long bones, 810 

— of pelvis, 801 

— of skull, 800, 801 

— ununited, 645, 802 
Friedrich's disease, 577 
Frontal lobe, tumours of, 497 
' Fungus of the navel,' 31 
Funicular hernia, 156 



Gangrene of the lung, 374 

— of the navel, 32 
Gastric catarrh, 90 

— juice, 6 

— pneumonia, 370 

— ulcer, 114 
Gastro-intestinal atrophy, 103 

catarrh, acute, 90 

chronic, 103 

— enteritis, 90 et seq. 

haemorrhage, 30 

Gastrostomy, 80 

General purulent peritonitis, 118 et seq. 

— surgical tuberculosis, 243 

— tuberculosis, 234 

Genital organs, haemorrhage from, 30 
Genito-urinary diseases, 592 

— organs, malformation of, 617 
Genu extrorsum, 213 

— recurvaturn, 749, 850 

— valgum, 211 et seq., 836 

degree of, to measure, 217 

from rickets, appearance of, 21 1, 

836 

— varum, 213 
Giant-foot. 429, 771 
Girdle-pain, 719 
Gland fever, 247 

Glands of groin, enlargement of, 692, 
693, 699 ... - 

— lymphatic, distribution of, 237 

— retroperitoneal, disease of, 444 

— bronchial, disease of, 387 



Glands, mesenteric, disease of, 144 

Glandular abscess, acute, 239, 240, 245 

Glottis, scald of, 345 

— spasm of the, 323, 328 

Goitre, 777 

Gonorrhoea, 37 

Gonorrhoeal rheumatism, 670 

' Graines jaunes,' 360 

' Grand mal,' 527 

Green-stick fractures, 204, 802 

Growing fever, 648 

Growth, arrest of, 210, 214, 216, 644, 

803 /£ seq., 851 
Gumma, scrofulous, 241 



H^MARTHROSIS, 44 1 

Haematoma of sterno-mastoid, 24, 740 

— occipital, 25 
Haematuria, 593 
Haemoglobliinuria, 420, 593 

— intermittent, 420, 594 
Haemophilia, 28, 440, 593 
Haemorrhage, 814 

— cerebral, 501, 504 

— gastro-intestinal, 30 

— genital organs, 30 

— medullary, 510 

— meningeal, 315, 502 

— newly born, 21 

— umbilical, 34 

Haemorrhagic diathesis, 28, 440, 593 
Haemorrhoids, 163 
Hallux flexus, 750 

— valgus, 750 
Hammer-toe, 750 
Hare-lip, 165 

— cases, feeble vitality in, 167 

— median, 174 

— operations, age for, 168 
Harvest bug, 797 
Headache, 543 

Head, cold in the, 754 

— injuries, 800 
Head-banging, 540 

— nodding, 539 

— shaking, 539 

Hearing in the newly born, 9 
Heart, diseases of, 396 

— dilatation of, 414 
Heart-disease, chronic, 410 

— congenital, 397 

— treatment of, 445 
Hemichorea, 517, 522 
Hemiplegia, 505 et seq. 

— from aneurism, 514 

— causes of, 505 et seq. 



884 



Index 



Hemiplegia from meningitis, 472 
Hepatic abscess, 190 
Hepatitis, interstitial, 1S8 

— syphilitic, 188, 453 
Hepatomphalos, 154 
Hereditary ataxic paraplegia, 577 

— syphilis, 447 
Hermaphrodites, 620 
Hernia, acquired, 156 

— of caecum, 157 

— cerebri, 501 

— congenital, 156 

— diaphragmatic, 154, 160 

— encysted, 156 

— femoral, 160 

— funicular, 156 

— infantile, 156 

— inguinal, 156 

— of liver, 154 

— of the ovary, 157, 631 

— radical cure of, T59 

— rectal, 16 r 

— strangulated, 157 

— translucency of, 157 

— umbilical. 155 

— and undescended testis, 628 

— ventral, 155 

Herpes zoster in spinal disease, 719 
Hiatus vesicce, 617 

— of abdominal wall, 155 
Hip disease, 687, 845 
acute, 690 

congenital, 751, 851 

double, 712 

— dislocation of, 696, 751, 812 

— excision of, 704, 847 

— reflex muscular spasm, 845 

— results, 846 
His, canal of, 179 
Hodgkin's disease, 439, 775 
Hollow claw-foot, 729 

— club-foot, 729 
Horse-shoe kidney, 596 
Hydatids of the liver, 190 
Hydrencephalocele, 570 
Hydrocele, T59, 633 

— of the neck, 176, 428, 774 
Hydrocephalic cry, 470 
Hydrocephalus, acute, 480, 485 

— chronic, 485 

— false, 94, 474 

— and spina bifida, 569 
Hydronephrosis, 601 
Hygroma, 176, 428, 774 
Hymen, imperforate, 625 
Hyperpyrexia in pneumonia, 370 
Hypertrophy of brain, 489 



Hypertrophy of face, 177 

— of labia, 625 

— of tonsils, 74 
Hypospadias, 620 
Hysteria, 540 
Hysterical chorea, 522 

— joints, 685 

— vomiting, 85, 542 
Hysteroid fits, 528 



Icterus neonatorum, 26 
Idiocy, 551 

— congential, 552 

— cretinoid, 559 

— developmental, 556 

— eclampsic, 555 

— epileptic, 555 

— microcephalic, 554 

— mongolian, 554 

— syphilitic, 557 
Idiopathic anaemia, 434 
lleo-umbilical diverticulum, 31, 15s 
Ileo-colitis, acute, 99 

Iliac abscess, 127 
Imitation in chorea, 516 
Immature infants, care of, 58 
Imperforate anus, 150 

— hymen, 625 

— rectum, 150 
Impetiginous eczema, 781 
Impetigo contagiosa, 787 
Implication of nerve in callus, 809 
Inanition fever, 39 
Incontinence of urine, 614 
Incubators, 59 

Indigestion, diet table in, 11 1 
Infancy, definition of, 1 

— dyspeptic diseases of, 83 

— mortality in, 14 
Infant, weight of, 10 
Infantile chorea, 90 

— convulsions, 532, 542 

— hernia, 156 

— intermittent fever, 300, 319 

— leucorrhcea, 241, 626 

— osteomalacia, 203 

— paralysis. 578, 736 

and hip-disease, 697, 698 

— scurvy, 192 
Infants, diet of, 39 

— feeding of, 39, 828 
Inflammatory diarrhoea, 90 

Inflation of intestine in intussusception, 

T38 
Influenza epidemic, 290 

— bacillus of, 291 



Index 



885 



Influerua, pneumonia in, 291 

— relapses in. 293 

— scarlatinal rash in, 292 

— tonsillitis in, 292 

— treatment of, 293 

— vomiting in, 292 
Inguinal adenitis, 692. 693, 699 

— colotomy, 152 

— hernia, 156 

Injections in intussusception, 138 
Injuries of soft parts, 800 
Intermittent fever, infantile, 300, 319 

— hemoglobinuria, 420, 594 
Interstitial hepatitis, 188 
Intestinal fistula, 124 

— ' kinks,' rig 

— obstruction, acute, 131 

— worms, 114 

Intestine, congenital obstruction of, 148 
Intra-uterine amputation. 744 

— life, 1 

— respiration, 3 
Intubation of larynx, 346, 830 
Intussusception, 131 

— abdominal section in, 139 

— of appendix, 142 

— chronic, 141 

— inflation in, 138 
Invagination of the bowel, 131 
' Inward fits,' 533 

Irritable mamma, 627 

— rugous bladder, 613 



Jaundice, catarrhal, 183 
Jaundice epidemic, 184 

— obstruction of duct, 182 

— of infants, 26 

— malignant, 184 

— in pneumonia, 370 
Jaw, ankylosis of, 685 
— = cysts of, 776 

Joint disease, pyaemic, 668, 841 

— sense, 691 

Joints, diseases of the, 660, 841 

— haemorrhage into, 441 
Jurymast, 721, 847 

Juxta epiphysary diaphysitis, 645 



Kidney, granular, 606 

— large white, 606 

— movable, 596 

— tumours of, 597 

Kidneys, congenital anomalies of, 596 

— diseases of, 596 
Kinks of intestine, 119 



Knee, diseases of, 661 et seq. , 845 
Knock-knee, 212 et seq., 836 

— from muscular spasm, 218 

— rickets, 211 et seq. 
Kyphosis, 210, 227 



Labia, hypertrophy of, 625 

— naevus of, 625 

— ulceration of, 626 
Labyrinth, affections of, 762 
Laminectomy, 725, 848 
Landry's paralysis, 577 
Laryngeal diphtheria, 332, 830 
Laryngismus stridulus, 323 
Laryngitis, catarrhal, 329 

— chronic, 343 

— spasmodic, 327 

Larynx, intubation of, 346, 830 

— papilloma of, 349 
Latent meningi is, 481 

Lateral curvature of spine, 223, 385, 837 

treatment, 837 

from caries, 717 

— meningocele, 566 

— sinus thrombosis, 763 
Late rickets, 216 

Leg, fractures of, 811, 841 
Leontiasis ossea, 659 
Leucocythaemia, 439 
Leucorrhoea, infantile, 241, 626 
Leukaemia, 439 
Lichen scrofulosus, 790 

— strophulus, 62, 791 

— urticatus, 790 
Lienteric diarrhoea, 87 
Life, intra-uterine, I 
Limbs, injuries of, 801 

— malformation of, 743 

— rickety, deformities of, 208 et seq., 
835 

Lip, cleft of lower, 174 
Lipoma, 770 
Lipomatous naevus, 428 
Lithaemia, 592 
Lithotomy, 611 
Lithotrity, 611 
Little's tin splint, 733 
Littre's operation, 152 
Liver, abscess of, 190 

— acute yellow atrophy of, 184 

— cirrhosis of, 186 

— diseases of, 181 

— enlargements of, 181 

— examination of, 181 

— fatty, 189 

— hernia of, 154 



886 



Index 



Liver, hydatids of, 190 

— lymphadertoma of, 191 

— size of, 181 

— syphilitic affections of, 187 

— tuberculosis of, 187, 189 

— tumours of, 191 
Lobar pneumonia, 366 
Lobelia in whooping-cough, 317 
Local anaesthesia, 818 
Lordosis, 210, 694 

Loss of blood, 814 
Ludwig's angina, 245 
Lumbar colotomy, 152 
Lungs, abscess of, 375 

— caseation of the, 3S8 

— chronic tuberculosis of, 390 

— collapse of, 353 

— gangrene of, 374 

— syphilitic affections of. 453 

— vital capacity of, at different ages, 4 
Lupus, 3S3, 798 

— hypertrophicus, 241 
Lymphadenoma, 775 

— of bronchial glands, 390 

— of liver, 191 
Lymphangiomata, cavernous, 428, 767 

— cystic, 428, 767 
Lymphangitis, reticular, 237 
Lymphatic anaemia, 439 

— glands, distribution of, 237 

— naevus, 428, 767 

— varix, 430 
Lymphoma, 775 
Lymphosarcoma, 775 



Macewen's operation, 221, 837 
Macrochilia, 175 
Macroglossia, 176, 427, 429, 767 
Macrostoma, 174 
Maculae, pigmentary, 424 
Malarial fever, 319 

Malformation of genito-urinary organs, 
617 

— of limbs, 743 

— of nose, 756 
Malignant jaundice, 1S4 

— disease of stomach, 113 

— polypi of nose, 757 
Malnutrition, 103 
Malunion of fractures, 812, 841 
Mamma, irritable, 627 
Maniacal chorea, 522 
Manipulation for club-foot, 848 
Mastoid disease, 760 et seq. 
Masturbation, 625 

Maternal impressions, 166 



Measles, 266 

— broncho pneumonia in, 270 

— diagnosis of, 271 

— eruption in, 269 

— incubation of, 268 

— laryngitis in, 270 

— mortality in, 267 

— glandular enlargement in, 271 

— micro-organisms in, 267 

— morbid anatomy of, 271 

— quarantine in, 273 

— treatment of, 272 

— tuberculosis in, 271 
Meat poisoning, 101 

Meatus urinarius, contraction of, 621 
Meckel's diverticulum, 31, 155 
Meconium, 7 
Median branchial fistula, 179 

— hare-lip, 174 
Mediastinal abscess, 389 
Mediastino-pericarditis, 417 
Medulla, tumours of, 496 
Medullary haemorrhage, 510 
Membrana tympani, rupture of, 759 
Membranous croup, see Diphtheria 

— laryngitis, 332 

Meningeal haemorrhage, 315, 502 

post partum, 502 

Meningitis, acute simple, 477 

— basal, 479 

— cerebro-spinal, 480 

— chronic, 4S2 

— latent, 481 

— in pneumonia, 370 

— purulent, 477, 481 

— simple, 477 

— spinal, 572 

— syphilitic, 482, 485 

— tubercular, 46S 

— vomiting in, 470 
Meningocele, 570 
Meningo-myelocele, 566 

Mental affections in childhood, 551 

— defect affecting speech, 549 

— strain, 469, 516 
Mesenteric disease, 144 
Metatarso-phalangeal disease, 684 
Methods of operating for hare-lip, 170 
Microstoma, 175 

Middle cerebral artery, thrombosis of, 

5ii 

— ear, diseases of, 475, 477, 498 et seq., 

759 
Midge bites, 797 
Miliaria, 791 

Miliary tuberculosis, acute, 232 
Milk, condensed, 53 



Index 



887 



Milk, composition of, 44 

— cows, 44, S52 

— human, composition of, 46 

— humanised, 48 

— modified, 48, 828 

— Pasteurization 0^829 

— peptonized, 52 

— tuberculous infection from, 145 
Misplaced testes, 627 

Mitral regurgitation, 410 et seq. 

Mixed nsevus, 422 

Mobile spasm, 508 

Moles, 799 

Monsters, 745 

Morbus coxae, 687 

Mortality after tracheotomy, 345 

— in infancy, 14 
Mother's mark, 421 
Mouth, absence of, 177 

— defects of, affecting speech, 160, 549 

— deformities of, 165 

— diseases of, 64 

— examination of, 60 
Mucoid cyst of tonsil. 74 
Mucous cyst of pharynx, 78 

— disease, 107 

— patches, 452 
Mumps, 318 

Muscle, artificial, 733, 737, 740 et seq. 
Muscles, deficiencies of, 743 

— sclerosis of, 591 
Muscular atrophy, 586, 591 

— spasm, 845. 
Myelitis, 575 
Myelocele, 566 
Myocarditis, 415 
Myositis ossificans, 743 
Myotome, 591 
Myxolipoma, 771 
Mvxcedema, 559 



N/EVUS, 421 

— congenital, 421 

— of labia, 625 

— lipomatodes, 428 

— lymphatic, 42S 

— orbital, 427 

— of rectum, 163, 424 

— of tongue, 177, 427, 429 
Narcotics, 856 

Nasal adenoid vegetations, 77 
Nasal catarrh, 754 

— deformity, 756 

— obstruction, 755 

— polypi, 756 
Navel, diseases of, 31 



Navel-urachus fistula, 31 
Necrosis, acute, 637 

— fracture after, 645 

— of jaw, 67, 655 

— of patella, 655 

— post-typhoid, 67 

— of rib — empyema, 643 

— of spinous process, 713, 724 
Nephritis, acute, 603 

— chronic, 605 

— in diphtheria, 284 

— in malarial fever, 319 

— in pneumonia. 370 

— in scarlet fever, 257 

— parenchymatous, 604 

— septic, 258 

Nerve, implication of, in callus, 899 
Nervous system, 8 

diseases of, 466 

Neuritis, 587 
Neuroma, 765 
Night cry, 691 

— starting, 69 c 

— terrors, 545 

' Nine-day fits,' 35 
Nitrous oxide gas, 818 
Nodes, 241, 648, 649 
Nodules, rheumatic, 460, 521 
Noma pudendi, 627 
Nose, diseases of, 754 

— dry catarrh of, 756 

— malformation of, 756 
Nystagmus, 539 



Oatmeal water, 51 
Obliteration of bile-ducts, 182 
Obstetrical paralysis, 25 
Obstruction of bowels, acute, 131 

chronic, 142 

congenital, 148 

Obturator teats, 168 
Obturators. 174 
Occipito-atlantoid disease. 713, 847 

— dislocation, 751, 801 
OZdema of scrotum, 625 

— neonatorum, 37 
Oesophageal glands, hypertrophy of, 

— varix, 81 
CEsophagitis, 81 
OZsophagotomy, 81 
Oesophagus, stricture of, 79, 180 

— deformities of, ,79, 180 

— foreign bodies in, 80 
Oidium lactis, 66 
Omphalitis, 32 ( 
Onychia, 797 



sss 



Index 



Onychia maligna, 707 
Open division in club-foot, 735, 848 
Operations under anaesthetics, 816 
Ophthalmia, gonorrhceal, 37 
Optic atrophy, 492 et seq. 

— neuritis, 233, 471, 492, 518 
Orbital naevus, 427 
Orchitis, 318, 628. 630, 631 
Osteoclasis, 220, 837 
Osteoma, 767 
Osteomalacia, infantile, 203 

— in rickets, 203 
Osteomyelitis, acute, 645 
circumscribed, 652 

— chronic circumscribed, 652 
diffuse, 654 

— condensing, 637, 656 

— pyemic, 657 

Osteophytic growths in rickets, 214 
Osteotomy, 221, 837 

— for flexed knee, 679 

— of ribs, 385 
Ostitis, 636 
Otitis externa, 759 

— in measles, 271 

— media, 475, 477, 498 et seq., 759 

— scarlet fever, 255 et seq. 
Ovarian hernia, 157, 631 

— tumours, 635 

Overgrowth of limbs from periostitis, 

644 
Overlying, 536 
Oxyuris, 114 
Ozaena, 756 



Pachydermatocele, 429 
Pachymeningitis, 485 
Packs in scarlet fever, 264 
Pain, 814 
Palate arch, shape of, 174 

— cleft of, 165 et seq 
Papilloma, 799 

— of branchial fissures, 180 

— of larynx, 349 

— of tongue, 177 

— of uvula, 77 

Paracentesis in pericardial effusion, 406, 

416 
Paralysis, acute atrophic, 578 
cerebral, 504 

— after diphtheria, 285 

— infantile, 578, 736 

— Landry's, 577 

— obstetrical, 25 

— pseudo-hypertrcphic, 588 
Paralytic chorea, 521 



Paralytic club-foot, 736 
Paraphimosis, 624 
Paraplegia, 573 

— ataxic, 577 

— cervical, 720 

— spastic, 501 

— in spina bifida, 566 et seq. 

— in spinal caries, 573, 720, 725 
Parasiiic foetus, 772, 774 
Parenchymatous nephritis, 604 
Parker's operation in club-foot, 734 
Parosteal abscess, 637 

Parotitis, 318 

Patella, dislocation of, 813 

in knock-knee, 215, 216, 217 

— necrosis of, 655 
Patent urachus, 31, 617 
Peliosis rheumatica, 444 
Pelvic abscess, 695 

— deformity in rickets, 210, 216 
Pemphigus. 791 

— syphilitic, 451 
Penis, absence of, 622 
Peri-articular abscess, 667, 693 
Pericarditis, 402 

— acute, 403 

— chronic. 406 

— diagnosis of, 403 

— symptoms of, 403 

— in chorea, 516 

— in nephiitis, 260 

— in rheumatism, 459 

— in scarlet fever, 257 
Pericardium adherent, 412 
Periglandular abscess, 240 
Perinephritic abscess, 599 
Pericesophageal abscess, 78, 80 
Periosteal abscess, 637 
Periostitis, 637 

— albuminosa, 652 

— chronic, 648 

— mixed infection in, C45 

— exanthematous, 643, 649 

— syphilitic, 649 
Peripheral neuritis, 5S7 
Perisigmoid abscess, 126, 127 
Peritoneal abscess, 120-127 

— effusion, chronic, 128 
Peritonitis, acute, 118 

— appendicular, 122 

— chronic, 117, 128 

cicatrisation from, 129 

— in enteric fever, 298 

— foetal, 149 

— in nephritis, 260 

— purulent, general, 120 

— tuberculous, chronic, 128 



Index 



I'erityphlitic abscess, 122-124, 127 

Perityphlitis, 122-124, 127 

Pernicious anaemia, 434 

Pes cavus, 729, 735 

in genu valgum, 215, 216 

— gigas, 429, 771 

— planus. 73S, 849 

— pronatus acquisitus, 738 
' Petit mal,' 527 
Pharyngeal tonsil. 77 
Pharyngitis. 77 
Pharynx, abscess of, 78 

— mucous cyst of, 78 
Phimosis, 622 
Phlebitis, umbilical, 34 

— lateral sinus, 763 
Phlegmonous periostitis, 37 
Phthisis, acute, 393 

— fibroid, 393 
Pigeon-breast, 201. 202 
Pigmentary maculae, 424 
Piles, 163 

Pinna, diseases of, 758 

— malformations of, 178 
Plaster-of- Paris jackets, 721 
Pleurisy, 375 

— in rheumatism. 459 
Pleuropneumonia, 370 

— in rheumatism, 459 
Pneumonia, abortive, 369 

— cerebral, 370 

— creeping, 370 

— croupous, 366 
pathology of, 372 

— gastric, 370 

— jaundice in, 370 

— in nephritis, 370 

— relapsing, 370 

— secondary, 357 
Polypi, nasal. 756 
Polypus recti, 163 

— umbilical, 31 
Polyuria, 464 

Pons, tumours of, 496 

Poroplasiic jackets, 723, 840 

Port-wine stain, 421 

Post-hemiplegic epilepsy, 529 

Post-nasal adenoids, 77 

Post-partum meningeal haemorrhage, 502 

Post-pharyngeal abscess, 78 

Pott's disease, 713, 847 

paraplegia in, 573, 720, 725, 847 

Prevertebral abscess, 78, 724 
Primary amputations, 812 

— resections, 812 

— union after excision of hip, 708, 712 
Prolapse of rectum, 160 



Prolapse, of urethra, 622 
Prostate, enlarged, 621 
Pseudo-diphtheria, 332 
Pseudo-hypertrophic paralysis, 588 
Pseudo-paralysis, syphilitic, 454, 650 
Psoas abscess, 697, 698, 715, 724 
Psoitis, 127 
Psoriasis, 791 

Psychical phenomena of infants, 10 
Pulpy disease of joints, 618 et seq. 
Pulse at birth, 5 
Pulsus paradoxus, 419 
Purgatives, 858 
Purpura, 442 

— haemorrhagica, 442 

— simplex, 442 

Purulent peritonitis, 120-127 
Pyaemia, 638, 657 et seq. 

— osteomyelitis in, 657 

— in periostitis, 638 et seq., 643 
Pyaemic joint-disease, 668 
Pyelitis, 602 

Pylorus, stenosis of, 112 
Pyuria, 594 



' Quiet strumous disease,' 663 
Quinine in pneumonia, 373 



Radical cure of hernia, 159 

Radius, subluxation of, 812 

Ranula, 176 

Rarefying ostitis, 636 

Raynaud's disease, 420 

Reaction of degeneration, 581 

Reclining board, 226 

Rectal abscess in sacral disease, 726 

— adenoma, 163 

— dermoid cysts, 164 

— fistula, 163 

— hernia, 161 

— naevus, 163, 424 

— polypus, 163 

— prolapse, 161 

— stricture, 164 

— ulcers, 164 

Rectangular talipes equinus, 729 

Rectum, imperforate, 152 

Recurved knee, 749, 850 

Red corpuscles at birth, 5 

' Redressement force ' in rickets, 220 

Reflex vomiting, 85 

Relapse after excision of tonsils, 76 

Relapsed club-foot, 733, 738 

— necrosis, 645 

Removal of sequestra from spine, 725 



890 



Index 



Removal of inflamed tonsils, 76 
Renal calculus, 602 

— new growths, 597 

Resection of bone in periostitis, 640 
Resections, primary, 812 
Residual abscess, 701, 706 
Respiration in newly born, 3 

— intra-uterine, 3 

— system, diseases of, 321 
Retention of urine, 616, 801 
Reticular lymphangitis, 237 
Retro-cesophageal abscess, 78, 80 
Retro-peritoneal glands, diseases of , 444 
Retro-pharyngeal abscess, 78, 80 
Rheumatic arthritis, 461, 669 

— nodules, 460 

— pericarditis, 459 
Rheumatism, 458, 519 

— chronic, 461 

— gonorrhceal, 670 
Rhinitis fibrinosa, 283 
Ribs, resection of, 385 
Rickets, 197 

— acute, 200 

— of adolescence, 216 

— in animals, 198 

— bone changes in, 204 

— causes of, 198 

— congenital, 203 

— deformities of, 208, 835 
treatment of, 218, S36 

— fcetal, 203 

— genu valgum from, 211, 837 

— scurvy in, 192 

— syphilis and, 108 

— visceral change in, 206 

— late, 216 

Rickety pelvis, 210, 216 

— spine, 2io, 836 

Rigidity of joints, congenital, 749 

Ringworm, 794 

Rizzoli's operation, 154, 837 

Roseola, lateral, 788 

Rotato-curvature of spine, 233, 385, 717, 

837 
Rotheln, 273 
Rubella, 273 

— complications of, 276 

— diagnosis of, 277 

— incubation in, 274 

— morbillosa, 275 

— quarantine in, 277 

— rash of, 275 

— scarlatinosa, 275 

— treatment of, 277 
Rugous bladder, 613 
Rupture, inguinal, 156 



Rupture, umbilical, 155 
— of urethra, 801 



Sacculi in lower lip, 174 
Sacral tumours, congenital, 772 

— dimple, 569 

— disease, 72O 
Sacroiliac disease, 6S4 
Saliva, secretion of, 6 

— composition of, 6 
Salivation in children, 457 
Sarcoma, 764 

— of kidney, 597 
Sayre's jacket, 721, 847 

' Scabbard trachea,' 778 
Scabies, 796 
Scalds, 813 

— of glottis, 345 
Scapula, deficiency of, 752 
Scarification of glottis, 345 
Scarlet fever, 249 

complications of, 255 

diagnosis of, 260 

enlarged glands in, 256 

incubation of, 251 

malignant, 254 

micrococci in, 262 

mild form of, 253 

morbid anatomy of, 261 

mortality of, 250 

nephritis in, 258 

otitis in, 255 

peritonitis in, 260 

pneumonia in, 256, 260 

prognosis in, 255 

pyaemia in, 257 

quarantine in, 266 

synovitis in, 256 

septicaemia in, 257 

surgical, 250 

symptoms of, 251 

treatment of, 262 

Scars, depressed, 243 
School-made chorea, 516 
Sclerema neonatorum, 36 
Sclerosis of bone, 637, 656 

— of brain, 488 

— of muscle, 591 
Scissor-legged deformity, 712 
Scoliosis, 225, 385, 717, 837 
Scorbutus, 192, 435 
Scrofula, types of, 236 
Scrofuloderma, 24 r_ 
Scrofulous gumma, 241 

— neck, 239, 240 
Scrotum, oedema of, 625 



Index 



Scurvy, 435 

— infantile, 192 
Seborrhcea, 787 
Separation of the cord, 31 

— of epiphyses, 803 
Septicaemia in scarlet fever, 257 
Septic diseases, 815 

— nephritis, 258 

Septum nasi, deviation of, 755 
Septum ventriculorum, open, 400 
Serous cysts, 430, 767 

— synovitis, 660, 667 
Shock, 814 

Shoulder, dislocations of, 751, 812 

— growing out of, 224 

— tuberculous disease of, 664, 843 
Sight in infants, 9 

Sinus, cavernous, thrombosis of, 763 

— cervicalis, 179 

— lateral, 763 

— umbilical, 124 
Siren foetus, 567 

Skin affections in syphilis, 451 

— diseases of. 780 
Skull, cubic capacity of, 8 

— fracture of, 800, 801 
Sleep, 10 

Softening of brain, 476, 514 
Spasm of glottis, 323, 328 
Spasmodic laryngitis, 327 

— torticollis, 742, 850 
Spastic paraplegia, 501 
Speech, anomalies of, 546 
Spina bifida, 566 

and hydrocephalus, 569 

occulta, 566 

Spinal abscess, 715, 717 

— caries, 7T3 

paralysis in, 573, 720, 725 

— deformity, angular, 713 
dyspnoea from, 329 

— meningitis, 572 

— meningocele, 566 

— rigidity, 718 

— sequestra, removal of, 725 

— splints, 721, 847 

— supports, 426, 720, 847 
Spine, forcible straightening, 224 

— lateral curvature of, 223, 385, 717, 837 

— operations on, 724, 825 

— periostitis of, 643 

— rickety, 210. 835 

— rotato-lateral curvature of, 223, 385, 
717, 837 

— weak, 224 

Spinous process, necrosis of, 713, 724 
Spleen, enlargement of, 436, 453 



Spleen, syphilitic affection of, 453 
Splenic anaemia, 436 

— enlargement in malaria, 319 
Sporadic cretinism, 559 
Spurious talipes valgus, 738, 849 
Stammering, 550 
Staphyloraphy, 172 

Status epilepticus, 529 
Steam tent, 330 
Stellate naevus, 421, 424 
Stenosis of the aorta, 401 

— of mitral valves, 401 

— of pulmonary artery, 400 

— of pylorus, 112 
Sterilisation of milk, 52 

Sterno- clavicular joint, disease of, 685 
Sterno-mastoid, haematoma of, 24, 740 

— tumour, 24, 740 
Sternum, fissure of, 752 
Stimulants, 860 

Stomach, capacity of, in infancy, 6 

— of infancy, 6 

— carcinoma of, 113 

— dilatation of, 112 

— malformations of, 113 

— ulcer of, 114 
Stomatitis, catarrhal, 64 

— gangrenous, 6g 

— haemorrhagic, 67 

— herpetic, 65 

— membranous, 65 

— parasitic, 64 

— ulcerative, 67 

Stone in the bladder, 609 
Strangulated hernia, 157 
Stricture of aesophagus, 79 

— of rectum, 164 

— of urethra, 621, 801 
Strophulus, 62, 791 
Strumous dactylitis, 657 

— nodes, 241 

— periosteal nodes, 648 
Subcutaneous naevus, 422 
Subjective symptoms of spinal disease, 

718 
Sublingual cysts, 176 
Subperiosteal abscess, 637 
Sudamina, 791 

Sudden death in nephritis, 260 
Sunstroke, 247 
Supernumerary auricles, 178 

— digits, 746 

— testes, 631 

Suppuration of bronchial glands, 387 
Suprapubic lithotomy, 611 
Suprascapula, development of, 752 
Surgical scarlet fever, 815 



8 9 : 



Index 



Surgical treatment of empyema, 382 

— tuberculosis, 243 
Swallowing foreign bodies, 80 
Syndactylism, 744 
Syndesmotomy, 734 
Synovitis, acute tuberculous, 672 

— of adolescents, 710 

— catarrhal, 668 

— exanthematous, 256, 660, 668 

— serous, 667 

— suppurative, 667 

— syphilitic, 669 

— tuberculous, 672 
Syphilis, 446 

— acquired, 446 

— arteritis. 454 

— brain affection in, 454, 482 

— congenital, 447 

— cranio-tabes.in, 450 

— eye affections in, 454 

— hepatitis in, 187, 453 

— hereditary, 447 

— lung affections in, 453 

— malnutrition in, 450 

— post- vaccinal, 447 

— skin affections in, 451 

— visceral lesions in, 453 
Syphilitic coryza, 452, 453 

— dactylitis, 657 

— epiphysitis, 454, 650 
Syphilitic hip-disease, 697, 698 

— idiocy, 454, 557 

— meningitis, 482, 485 

— ostitis, 454 et seq. 

— pemphigus, 451 

— pseudo-paralysis, 454, 650 

— spleen, 453 

— teeth, 454 

— telostitis, 454, 650 

— testitis, 632 
Syringo-myelocele, 566 



TAENIA mediocanellata, 116 

— solium, 116 
Talipes, acquired, 727 

— calcaneus, 729, 738 
— ■ cavus, 729 

— equino-varus, 569 727, 848 

— paralytic, 736, 848 

— valgus, 728, 848 

— varus, 727 
Tape-worm, 116 
Tarsectomy, 682 

— for club-foot, 735 
Taste in infants, 10 
Teeth, eruption of, 12 



Teeth, syphilitic, 454 
Telangiectasis, 421 
Telostitis, 454, 650 
Temperature in health, 8 

— at birth, 8 
Tenosynovitis, 743 

Tenotomy for club-foot, 734 et seq., 848 
Tent, steam, for laryngitis, 330 
Testis, abnormalities of, 627 

— diseases of, 631 

— inflammation of, 631 

— syphilitic, 632 

— torsion of, 632 

— tubercle of, 632 

— tumours, 633 

— undescended, 267 
Tetanus nascentium, 35 
Tetany, 537 

Thigh, fractures of, 811 

Thomas's splints, 673, 705, 722, 847 

Thomsen's disease, 591 

Thorax in infancy, 321 

Thread-worms, 114 

Thrombosis of cerebral sinuses, 514 

Thrush, 65 

Thumb-sucking, deformity from, 177 

Thymus, 778 

Thyroid, diseases of, 777 

— duct cysts, 179, 180 
Thyro-glossal duct, 179 
Thyrotomy, 349 

Tibia, deformities of, 213 et seq. 
Tinea circinata, 794 

— tonsurans, 793 

Toes, diseases of, 684, 771 
Tongue, absence of, 175 

— condyloma of, 177 

— malformations of, 175 

— nsevus of, 177, 427, 429 

— papilloma of, 177 

— swallowing, 176 

— tumours of, 177 
Tongue-tie, 175 
Tonsil, cyst of, 74 

— enucleation of, 76 

— guillotine, 76 

— pharyngeal, 77 

Tonsils, removal of inflamed, 76 
Tonsillar calculus, 76 

— hypertrophy, 74 
Tonsillitis, acute, 70 

— chronic, 74 
Torsion of testis, 632 
Torticollis, 24, 741, 850 
Trachea, aspirator for, 340 

— compression of, 328 

— ulceration of, 343, 344, 34S 



Index 



893 



Tracheal dilator, 340 

— fistulse, 180 

— stenosis, 344 
Tracheotomy, 336 

— tubes, 342 

Traction diverticula of gullet, 79 
Translucent hernia, 157 
Transpatellar excision, 677 
Transposition of aorta, 402 
Transverse myelitis, 575 
Traumatic stricture of urethra, 801 
Travelling acetabulum, 689 
Trephining skull, 499, 762, 763 

— for epilepsy, 531 

— spine. 725 
Trismus neonatorum, 35 
Trochanter, disease of, 698 
Trophic ulcers, 567, 570 
Trusses, 158 

Tubercles of choroid, 233 
'Tuberculosis of adrenals, 607 

— acute miliary, 232 

— chronic, of lung, 390 

— congenital, 228 

— general, 234 

sub-acute, 234 

surgical, 243, 841 

— of liver, 187, 189 

— broncho-pneumonia, form of, 232 

— primary infection, 841 
Tuherculosis and scrofula, 236 

— typhoid form of, 232 
Tuberculous abscess of kidney, 600 

— adenitis, 237 

— cystitis, 613 

— dactylitis, 657 

— disease of ankle, 666 
of elbow, 664, 843 

— embolism, 229, 237 

— infection from milk, 145 

— kidney, 6co 

— meningitis, 468 

anatomy of, 475 

symptoms of, 469 

treatment of, 476 

— peritonitis, chronic, 128 

— shoulder, 664, 843 

— synovitis, 660 et seq. 
acute, 672 

— testis, 632 

— ulceration of bowel, 144 

— ulcers, 241 

— wrist, 664, 843 

Tubes for tracheotomy, 342 
Tumour growth, 764 
Tumours of basal ganglia, 496 

— of bladder, 613 



Tumours of brain, 491 

— of cerebellum, 493 

— cerebral, 491 
removal of, 499 

— congenital, 764 et seq. 

— of frontal lobe, 497 

— of kidneys, 597 

— of liver, 191 

— of ovary, 635 

— of pons, 496 

— of testis, 633 
Types of scrofula, 236 
Typhlo-peritonitis, 122 
Typhoid form of tuberculosis, 232 

— fever, 293 

— periostitis, 643, 649 

— synovitis, 668 
Typhus, 303 

— diagnosis of, 305 

— mortality in, 303 

— rash in, 304 

— symptoms of, 303 

— treatment of, 305 



Ulceration of bone, tubercular, 636 

— of labia, 241, 626 

— - of navel, 32 

— of nose, 756 

— of trachea, 343, 348 
Ulcerative endocarditis, 336 

— stomatitis, 62 
Ulcers of the anus, 155 

— of the rectum, 155 

— of the stomach, 114 

— trophic. 567, 570 

— tuberculous, 241 

— vulvar, 241, 626 
Umbilical arteritis, 33 

— fistula, 124 

— hemorrhage, 34 

— hernia, 155 

— phlebitis, 34 

— polypus, 31 

— sinus, 124 

Umbilicus, deformities of, 154 

— diseases of, 31 

— gangrene of. 32 

— ulceration of, 32 
Undescended testes, 627 

Union of epiphyses, dates of, 810 
Ununited fractures, 645, 802, 841 

from necrosis, 645 

Uraemia in scarlatinal nephritis, 259 
Urachus, patent, 31, 617 
Uranoplasty, 173 
Urethra, obliteration of, 621 



8 9 4 



Index 



Urethra, double, 622 

— prolapse of, 622 

— rupture of, 801 

— stricture of, 62 r 

Urinary meatus, tumour of, 622 

— organs, diseases of, 592 
Urine, composition of, 7 

— extravasation of, 610, 617, 801 

— incontinence of, 614 

— retention of, 616 
Urticaria, 790 

Uvula, enlargement of, 77 

— naevus of, 427 

— papilloma of, 77 



Vaccination, erythema after, 310 

— erysipelas after, 310 

— glandular enlargement after, 310 

— performance of, 309 

— rashes after, 310 
Vaccino-syphilis, 310, 447 

Vaginal discharge, due to worms, 114 

— haemorrhage, 30 
Vaginitis, 625 

Vapour baths, in nephritis, 265 
Varicella, 305 

— contagious nature of, 306 

— diagnosis of, 308 

— eruption in, 307 

— gangraenosa, 307 

— incubation of, 307 

— quarantine in, 308 

— treatment of, 309 
Varicocele, 635 
Varioloid, 311 

— diagnosis of, 312 

— treatment of, 312 

Varix, arteriovenous, 427, 428 

— lymphatic, 430 

— of oesophagus, 81 
Veal tea, 853 
Venous naevus, 421 
Ventral hernia, 155 
Vertebral osteomyelitis, 643 
Vesical calculus, 609 
Vicarious emphysema, 360 
Visceral naevus, 424 

Vital capacity of lungs, 4 
Vomiting, chronic, 105 

— in cerebral tumour, 492 



Vomiting in chloroform anaesthesia, 823 

— in gastric catarrh, 84 

— in hysteria, 85, 542 

— in infants, 84 

— in meningitis, 470 

— in obstruction of the bowels, 133 

— in peritonitis, 119 

— in scarlet fever, 251 

— in whooping-cough, 314 
Vulvar anus, 150 

— ulcers, 241, 626 
Vulvitis, 625 



Warts of vulva, 627 
Water on the brain, 94, 474 
Weak spine, 224 
Weaning, 42 
Web-fingers, 74S 

— toes, 699 

Weight and height, 864 

— chart, 11 

— increase of, 1 1 
Wet nurses, 41 
Whey, 50 

' White lock-jaw,' 36 
Whooping-cough. 312 

— broncho-pneumonia in, 315 

— contagiousness of, 313 

— convulsions in, 315 

— diagnosis of, 315 

— diarrhoea in, 315 

— emphysema in, 315 

— incubation of, 313 

— pathology of, 316 

— treatment of, 316 

— tuberculosis after, 315 
Winckel's disease, 29 
Worms, intestinal, 114 

— round, 115 

— tape, 116 

— thread, 114 

Wound management, 815 
Wrist joint, disease of, 664, 843 
Wryneck, 741, 850 

Youth, 2 



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II INI I hil II II 1 1 1 II II II II 
022 216 177 



